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Kennedy Institute of Ethics Journal Vol. 26, No. 2, 105–144 © 2016 by The Johns Hopkins University Press
Brian D. Earp
Between Moral Relativism and Moral Hypocrisy:
Reframing the Debate on “FGM”
ABSTRACT. The spectrum of practices termed “Female Genital Mutilation” (or
FGM) by the World Health Organization is sometimes held up as a counterex-
ample to moral relativism. Those who advance this line of thought suggest the
practices are so harmful in terms of their physical and emotional consequences,
as well as so problematic in terms of their sexist or oppressive implications, that
they provide sufficient, rational grounds for the assertion of a universal moral
claim—namely, that all forms of FGM are wrong, regardless of the cultural
context. However, others point to cultural bias and moral double standards on
the part of those who espouse this argument, and have begun to question the
received interpretation of the relevant empirical data on FGM as well. In this
article I assess the merits of these competing perspectives. I argue that each of
them involves valid moral concerns that should be taken seriously in order to
move the discussion forward. In doing so, I draw on the biomedical “enhance-
ment” literature in order to develop a novel ethical framework for evaluating
FGM (and related interventions—such as female genital “cosmetic” surgery and
nontherapeutic male circumcision) that takes into account the genuine harms that
are at stake in these procedures, but which does not suffer from being based on
cultural or moral double standards.
INTRODUCTION
“Female Genital Mutilation” or FGM—the terminology is ex-
tremely contentious1—is sometimes held up as a counterexam-
ple to moral relativism (see, e.g., Hernlund and Shell-Duncan
2007; Kopelman 1994; Lane and Rubenstein 1996; Shweder 2002).2
Those who advance this line of thought suggest that such mutilation is
so harmful in terms of its physical and emotional consequences, as well
as so problematic in terms of its sexist or oppressive implications, that it
provides sufficient, rational grounds for the assertion of a universal moral
claim—namely, that all forms of FGM are wrong, regardless of the cultural
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context. Prominent philosophers who have argued for this position, or
one reasonably close to it, include Martha Nussbaum3 (1996, 1999), Ruth
Macklin (1998), Amy Gutmann (1993), and many others, and it has been
adopted as official policy by such influential bodies as the World Health
Organization (WHO) and the United Nations (UN). In 2008, for example,
the WHO/UN published a joint statement calling for the “eradication”
of FGM (WHO/UN 2008); four years later, the UN passed a unanimous
resolution effectively “banning” the practice all around the world (see
UN Women 2012).
In both cases, the policies were justified, at least in part, by an appeal to
objective or universal moral principles, typically expressed in the language
of human rights (for further discussion, see Askew et al. 2016).4 According
to the 2008 joint statement, for example, FGM “violates the right [to]
physical integrity of the person” (WHO/UN 2008, 1). According to the
2012 UN resolution, FGM is an “irreparable, irreversible abuse” that
violates “human rights” (United Nations General Assembly 2012, 2).
Many people have celebrated these (and other similar) developments
and have hailed them as advances in the cause of social justice. Certainly,
this appears to be the prevailing view among Western5 bioethicists and
moral philosophers, who are inclined to see the reasoning of the anti-
FGM universalists as being both dispassionate and empirically well-
informed. However, others suggest that cultural bias may be corrupting
the conventional analysis—and have raised serious questions about the
standard interpretation of the relevant “facts” about FGM as well (e.g.,
Abdulcadir et al. 2012; Ahmadu 2000, 2007, 2016; Ahmadu and Shweder
2009; Androus 2004, 2009, 2013; Arora and Jacobs 2016; Bell 2005;
Benatar and Benatar 2003; Bishop 2004; Boddy 1991; van den Brink and
Tigchelaar 2012; Chase 2005; Coleman 1998; Darby 2015; Davis 2001,
2002, 2013; DeLaet 2009, 2012; Fox and Thomson 2005, 2009; Frissa
2011; Galeotti 2007; Gruenbaum 2001; Gunning 1991; Hellsten 2004;
Hernlund and Shell-Duncan 2007; Hodžic´ 2013; James and Robertson
2005; Johnsdotter and Essén 2010, 2016; Johnson 2010, 2014; Johnson
and O’Branski 2013; Kirby 1987; Lane and Rubenstein 1996; Lightfoot-
Klein 1997; Lightfoot-Klein et al. 2000; Lyons 2007; Manderson 2004;
Mason 2001; Njambi 2004; Oba 2008; Obermeyer 1999, 2003, 2005;
Sanchez 2014; Shell-Duncan and Hernlund 2000; Shweder 2002, 2005,
2013; Smith 2011; Svoboda 2013; Svoboda and Darby 2008; Toubia
1999; Wade 2009, 2012a, 2012b; Wisdom 2012; Wong 2006).
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Although these emerging critics do not speak in one voice, it is worth
noting that they include a number of academics who have described
themselves as being personally opposed to FGM or even strongly in favor
of its discontinuance (e.g., Androus 2004, 2009; Boddy 1991; James and
Robertson 2005), as well as some scholar-activists and feminists who have
been at the very forefront of the anti-FGM movement (e.g., Lightfoot-Klein
1997; Lightfoot-Klein et al. 2000; Toubia 1999). According to these critics,
the prevailing moral discourse surrounding FGM has not been entirely
objective, but has instead been compromised by what they see as Western
ethnocentrism and cultural imperialism (see Gunning 1991, 191; see also
Oba 2008). Some of these critics have gone even further and raised a charge
of outright moral hypocrisy (e.g., Baker 1998; DeLaet 2009; Dustin 2010;
Ehrenreich and Barr 2005; Ford 2001; Johnson 2010).
What would such hypocrisy mean in this case? In simplest terms, it
would mean that the specific moral principles that are currently being used
to justify a “zero-tolerance” stance on FGM (both philosophically and
in terms of actual global policy; see Topping 2015) are not being applied
consistently to analogous practices that happen to be more popular in
Western countries.6 Examples that have been raised in the literature of
such potentially analogous practices include: female “cosmetic” surgeries
such as breast implantation, along with female “cosmetic” genital surgeries
in particular (see, e.g., Chambers 2004, 2008; Davis 2002; Johnsdotter
and Essén 2010; Kelly and Foster 2012; Sheldon and Wilkinson 1998;
Svoboda 2013), intersex genital “normalization” surgeries (see, e.g., Chase
2005; Ehrenreich and Barr 2005; Ford 2001; Lightfoot-Klein et al. 2000;
Svoboda 2013), and nontherapeutic infant male circumcision (see, e.g., Bell
2005; Chambers 2008; Davis 2001; Earp 2015a; Hellsten 2004; Johnson
2010; Svoboda and Darby 2008; Toubia 1999). These practices, perhaps
because they are more familiar to a Western mindset, might be presumed
to be morally unproblematic—or at least, on the whole, permissible—
even if a more careful analysis would reveal that they share a number of
features with FGM that should qualify them as being comparably morally
suspicious. In other words, these critics argue, it might be the case that
what appears to be a universal moral standard concerning FGM will turn
out to be, upon closer inspection, a “relativistic double standard that
masquerades as universalism” (DeLaet 2009, 422).
In this article, I assess the merits of these competing perspectives. I argue
that each of them involves valid moral concerns that should be taken
seriously in order to move the discussion forward. Accordingly, my aim
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will be to develop an ethical framework concerning FGM (and related
interventions) that acknowledges the genuine harms that are at stake, but
which does not suffer from being based on cultural double standards. In
order to develop this framework, I will begin by presenting the orthodox
position on FGM as represented by the WHO/UN, and then I will turn
to the analysis of the critics of this position who have raised the concerns
about cultural bias.
WHAT IS THE POSITION OF THE WHO/UN?
According to the WHO/UN (2008), the term “Female Genital
Mutilation” refers to “all procedures involving partial or total removal
of the external female genitalia [i.e., the external clitoris, clitoral prepuce,
and labia] or other injury to the female genital organs for non-medical
reasons” (1). The most invasive form of FGM is called “infibulation,”
which is defined as the “narrowing of the vaginal orifice with [the] creation
of a covering seal by cutting and appositioning the labia minora and/or the
labia majora, with or without excision of the clitoris” (24). Other, more
“minor” forms of FGM will be discussed in detail later on.
Such “mutilation” has “no known health benefits,” according to the
WHO/UN (2008), but instead is “known to be harmful to girls and women
in many ways” (1). For example: “it is painful and traumatic. The removal
of or damage to healthy, normal genital tissue interferes with the natural
functioning of the body and causes several immediate and long-term
health consequences” (1). Such consequences may include “chronic pain,
infections, decreased sexual enjoyment, and psychological consequences,
such as post-traumatic stress disorder” (11).
Although the WHO/UN acknowledge that “communities that practise
female genital mutilation report a variety of social and religious reasons
for continuing with it,” they suggest that these reasons are not sufficient
to justify the practice on moral grounds. Instead, “from a human rights
perspective,” FGM reflects “deep-rooted inequality between the sexes, and
constitutes an extreme form of discrimination against women.” Moreover,
since “female genital mutilation is nearly always carried out on minors it
is therefore a violation of the rights of the child” (2008, 1).
As we can see, the WHO/UN position rests on a number of specific moral
as well as empirical considerations. Taken together, these considerations
are believed to justify a concerted effort on their part to “eradicate” all
forms of FGM, including from the countries and cultures in which it has
long been performed and continues to be widely endorsed. As noted earlier,
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however, this position is not unique to the WHO/UN. Instead, it is typical
of—and indeed, very heavily informed by—the broader Western discourse
on the subject. Therefore it is important to try to understand why some
people have raised concerns about this broader discourse, so that we can
see how those concerns might apply to the specific claims that have been
advanced by the WHO/UN.
WHAT ARE THE CONCERNS OF THE CRITICS?
That the WHO/UN position on FGM might be controversial is likely
to come as a surprise to many people. As Richard Shweder (2002) has
noted, the apparent Western consensus about FGM is that it is so clearly
beyond the pale—even barbaric, as it is often said—that “the mere query,
‘What about FGM?’ is [now] presumed to function in and of itself as a
knockdown argument against both cultural pluralism and any inclination
toward tolerance” (226). But a perception of consensus can also breed
complacency. In particular, it can lead to an echo chamber of mutual
agreement that might make it hard to be properly self-critical, much
less open to the possibility of dissent. Consistent with this view, as Lori
Leonard (2000) has argued, the Western literature on FGM has become
“remarkably constrained and predictable, bearing signs of an almost
standardized discourse” (159).
A standardized discourse might still be—for the most part—an accurate
discourse, or a discourse that is accurate enough. In this case, however,
the emerging critical view is that it is neither. Instead, these critics suggest,
it is characterized by such problems as oversimplification, unjustified
conflation of disparate phenomena, exaggeration, and often extremely
emotive rhetoric7 that is not supported by dispassionate research (James
and Robertson 2005). As Andrew Delaney (2013) has argued, “research
and activism [have been largely] conflated . . . and data on FGM that [are
not] actually investigated taken as true” (see also Hodžic´ 2013; Johnsdotter
2013; Johnsdotter and Essén 2010; Obermeyer 1999; Shweder 2002).
We will look at some examples of this phenomenon a little bit later on.
In light of these sorts of considerations, some scholars who work on
FGM have expressed concern about the degree of insularity that is present
in the Western discourse on the subject (see, e.g., Abdulcadir et al. 2012).
Since FGM is a foreign practice with respect to this discourse, they argue, it
might be hard for some people—including not only members of the general
public, but also government officials, journalists, policymakers, medical
researchers, moral philosophers, and even some Western feminists and
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anthropologists—to take seriously the perspective of cultural “insiders”
who regard FGM as something “normal” (see, e.g., Berggren et al. 2007;
Ahmadu 2000; Kirby 1987).8 As a result, they might fail to understand
the complexity of the actual contexts associated with FGM, including not
only the abstract interpretive standards by which the practice is locally
evaluated, but also the range of purely physical consequences it can have
for health and sexuality. As Carla Obermeyer (1999) has written:
It is rarely pointed out that the frequency and severity of complications
are a function of the extent and circumstances of the operation and it is
not usually recognized that much of [our] information comes from studies
of the Sudan, where [in contrast to the majority of settings] most women
are infibulated. The ill-health and death that these practices are thought
to cause are difficult to reconcile with the reality of their persistence in so
many societies, and raises the question of a possible discrepancy between
our “knowledge” of their harmful effects and the behavior of millions of
women and their families. (91)
What might explain this discrepancy, should we find that it exists
(as I will argue that it does in the course of what follows)? Part of the
explanation, as the Sierra Leonean–American anthropologist Fuambai
Ahmadu (2007) has put it, has to do with the tendency of Western
observers to direct their gaze “between the legs” of women who are
affected by FGM, rather than on the wider circumstances of their lived
experiences. This has the effect, she argues, of negating their beliefs and
feelings about the practice, “rendering them ‘invisible’ as individuals with
their own dynamic histories, cultures, and traditions” (279).
What might Westerners notice if they were to lift up their gaze? One
thing they might notice is that “coming-of-age and gender-identity [rites]
involving genital alterations are embraced by, and deeply embedded in
the lives of many African women” (Shweder 2002, 218).8 Such rites are
also common, in one form or another, in some parts of Southeast Asia and
the Arabian peninsula, as well as in a number of immigrant communities
derived from these populations. Moreover, the women who participate
in (and perpetuate) these rites come from a range of different ethnic and
religious backgrounds, as well as social and economic classes; and they
run the gamut of educational attainment (see Abdulcadir et al. 2012;
Shweder 2002). In these groups, what is usually referred to (in English) as
“female circumcision”—rather than “mutilation”—is typically regarded as
a cause for celebration: it is often accompanied by ceremonies intended to
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honor the girls and welcome them into the adult community (Kopelman
1994, 55).
Of course, the mere popularity of a given practice in a given context
does not necessarily tell us very much about its underlying moral character.
As I have argued elsewhere, it is quite possible that those women who
approve of female circumcision in their societies “possess a comparatively
narrow degree of awareness of the key issues, such as the relevant genital
anatomy, the ethical controversies surrounding the practice, the way it is
perceived in other societies, and so on” (Earp 2015a, 96; see also Dalal,
Lawoko, and Jansson 2010). Nevertheless, critics of what I have been
calling the orthodox view have noted that these women—that is, those
who are supportive of female circumcision, and who have actually gone
through a version of it themselves—are not typically given standing in
the international debate.9 Instead, their voices have been for the most
part ignored, or, if acknowledged, explained away, often by appeals
to “patriarchy” or “false consciousness”10 that are based largely upon
untested assumptions rather than carefully collected evidence (Ahmadu
2000, 2007; Engle 1992; Haddon 1998; Lewis 1995; Lyons 2007; Obiora
1997; Shweder 2002). For example, it is often asserted that female
circumcision is done at the behest of men (whether directly or indirectly)
as a way to “control the sexuality” of women. On this interpretation,
women who endorse or even manage such rituals themselves—as they do
in the vast majority of cases (Abdulcadir et al. 2012; Shweder 2002)—are
unwittingly participating in their own subordination.
The Question of Patriarchy
Researchers who have looked more closely at the question of patriarchy—
here defined as “a system of social structures and practices in which men
dominate, oppress, and exploit women” (Walby 1989, 214)—emphasize
that there is a wide “diversity of female genital cutting practices” across
cultures (Johnson and O’Branski 2013, 211), and that these are carried
out by different groups, under different circumstances, for a multiplicity
of reasons (Lyons 2007). In some cases, the motivation for the cutting has
little to do with curbing sexuality (see, e.g., Shell-Duncan and Hernlund
2000); and the relationship to patriarchy across these various settings is
at best unclear.11 For example, while some groups that practice female
genital cutting appear to be characterized by power imbalances that favor
males, others are more egalitarian (see later discussion). More importantly,
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however, there does not seem to be any consistent relationship between
the respective status of men versus women in some society and whether it
practices a form of FGM. This point has recently been underlined by the
Public Policy Advisory Network on Female Genital Surgeries in Africa, a
nonpartisan, interdisciplinary coalition of some of the foremost scholars
of genital cutting. As these authors state: “The vast majority of the world’s
societies can be described as patriarchal, and most either do not modify the
genitals of either sex or modify the genitals of males only. There are almost
no patriarchal societies with customary genital surgeries for females only”
(Abdulcadir et al. 2012, 23). We will return to this point in a moment.
As for the act of cutting itself, as Mackie (2000) has stated, “a group
may perform it at infancy, before puberty, at puberty, with or without
initiation rites, upon contracting marriage, in the seventh month of the first
pregnancy, [or] after the birth of the first child” (270). In some cases, FGM
has been done (by women) over the objections of the majority of men (see
Thomas 1996); in other cases it has been adopted by teenage girls over the
objections of the entire adult community (see Leonard 2000). More often,
however, it is done around puberty as part of a rite of passage, with men,
women, and teenagers typically supporting the initiation. As Lisa Wade
(2012a) has argued, attributing the persistence of female genital altering
rituals to patriarchy “grossly over-simplifies their social, cultural, and
economic functions” in the diverse societies in which they are performed
(28; see also Obiora 1997).
Male Circumcision
Another point to consider when analyzing the role of patriarchy in
upholding genital cutting practices is that it isn’t only the girls who are
initiated. The boys are circumcised as well. As alluded to in the previous
section, there are few or no human societies on record that practice
female genital cutting without also practicing male genital cutting—often
in parallel, under the same conditions, and for very similar reasons (see,
e.g., Ahmadu and Shweder 2009; Androus 2013; Caldwell, Orubuloye,
Caldwell 1997; DeLaet 2009; Leonard 2000; Manderson 2004). As J.
Steven Svoboda (2013) notes, across societies, analogous justifications are
given for both male and female genital reshaping customs: “these include
claimed health benefits, absence of ‘bad’ genital odors, enhancement of
physical beauty, greater attractiveness and acceptability of the sex organs,
[spurious] medical reasons, minimization of damage and pain, hygiene,
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preventing future problems . . . looking like other children or like the
child’s parents, fear of promiscuity, and acceptance of altered genitalia
as more [appealing] to the opposite sex” (244). Providing an additional
perspective, Lori Leonard (2000) has written:
When practiced as part of a rite of passage, [male and female] genital cutting
simultaneously separates initiates from the asexual world of childhood and
incorporates them into [the] world of adulthood. In such contexts, genital
cutting is construed as having little to do with sex, per se. Rather, its function
is to prepare young men and women to occupy [their adult roles] within
the community. (162)
Nelson Mandela’s (2008) account in The Long Walk to Freedom of his
own ritual circumcision among the Xhosa is consistent with this view:
When I was sixteen, the regent decided that it was time that I became a man.
In Xhosa tradition, this is achieved through one means only: circumcision.
In my tradition, an uncircumcised male [cannot] marry or officiate in tribal
rituals. An uncircumcised Xhosa man is a contradiction in terms, for he is
not considered a man at all, but a boy. (30–36)
As Mandela goes on to say, “It was a sacred time; I felt happy and fulfilled
taking part in my people’s customs and ready to make the transition from
boyhood to manhood.” At the same time, however, “I was also tense
and anxious, uncertain of how I would react when the critical moment
came.” For, among the Xhosa, as in many other African ethnic groups,
“circumcision is a trial of bravery and stoicism; no anaesthetic is used; a
man must suffer in silence” (ibid.).12
In some societies where male and female circumcisions are performed,
the operations are seen as mirror images of each other. That is, male
circumcision is regarded as removing the “female” part of the penis
(namely, the foreskin, which encloses, like a womb or vagina), whereas
female circumcision is regarded as removing the “male” part of the vulva
(namely, the external clitoris, which sticks out like a miniature phallus).
In this way, “androgynous” children are transformed into fully sexualized
adults with distinct sex-based characteristics (see Ahmadu and Shweder
2009; Shell-Duncan and Hernlund 2000). Lest this way of thinking seem
too alien, it may be useful to raise an analogy here with the Western practice
of surgically “normalizing” the genitals of so-called intersex children—i.e.,
children who are born with what their community regards as insufficiently
differentiated genitalia (for further discussion, see, e.g., Dreger 1998,
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1999; Ehrenreich and Barr 2005; Ford 2001; Karkazis 2008). In any case,
as Zachary Androus (2004) has noted, it is important to recognize that
female and male genital altering rituals are often “closely related in the
practitioners’ minds” (6).
John Caldwell and his colleagues offer a similar perspective. “The failure
to relate the two types of circumcision,” they write, “is curious . . . because
they have probably been regarded by most Africans as being related for
aeons” (Caldwell, Orubuloye, and Caldwell 1997, 1181). In consequence,
many African women and men are genuinely perplexed by what they
see as Western efforts to eliminate only the female half of their initiation
rites. Recognizing this, one scholar of genital cutting has suggested that:
“Female circumcision will never stop as long as male circumcision is going
on . . . [for how] do you expect to convince an African father to leave his
daughter uncircumcised as long as you let him do it to his son?” (quoted
in Abu-Sahlieh 1993, 612; see also Steinfeld and Lyssarides 2015).
Against this view, some might wish to argue that a clear distinction
can nevertheless be drawn between the two types of genital cutting. This
would be based on the assumption that female forms of circumcision are
more invasive, more medically risky, and more physically harmful than
their male counterparts. But it is hard to see on what empirical grounds
such a categorical perspective could successfully be advanced. To pick
just one example, in South Africa in 2013, nearly 80 teenage boys died
from their traditional circumcision initiations, very much like the one
described by Mandela (Maseko 2013); between 2008 and 2014 the total
figure for circumcision-related deaths in South Africa was conservatively
400 in just two of the nine provinces, with several thousands of boys
being hospitalized due to seriously botched operations (Gonzalez 2014;
Douglas and Nyembezi 2015). Most of these procedures were carried out
in the bush, with nonsterilized tools such as spearheads and dirty knives,
by ritual practitioners with little or no medical training (see, e.g., Malan
2013). Among those who did not die, several lost their penises or suffered
partial amputations, and dozens more suffered from such conditions as
necrosis and severe infections (for extensive photographic evidence, see
the website http://ulwaluko.co.za). In this same time period, however,
there were no known deaths from female circumcision in South Africa,
probably because the Xhosa ritual for girls is much shorter than the one
for boys and does not involve the actual removal of tissue (South African
History Online 2014); otherwise, female genital cutting in South Africa
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appears to be limited to a handful of immigrant groups, with no reliable
prevalence statistics available (see Interparliamentary Union 2002).
The situation varies from group to group. To be certain, as Debra DeLaet
(2009) points out, “there are sharp differences between infibulation, the
most extreme form . . . of female genital mutilation, and the less invasive
form of male circumcision that is most widely practiced.” However: “that
comparison is not necessarily the most appropriate comparison that can be
made. There are extremely invasive forms of male circumcision that are as
harsh as infibulation” (406), such as subincision, traditionally practiced by
some Australian Aboriginal groups, in which the underside of the penis is
sliced open from the scrotum to the corona of the glans (see, e.g., Cawte,
Djagamara, and Barrett 1966; Pounder 1983; Rowanchilde 1996); and
while “it is true that these extreme forms of male circumcision are rare .
. . it is also the case that infibulation” is rare, occurring in approximately
10% of cases according to available estimates (see Abdulcadir et al. 2012;
Yoder and Kahn 2008). “Indeed, female circumcision as it is commonly
practiced can be as limited in terms of the procedures that are performed
and their effects as the most widespread type of male circumcision”
(DeLaet 2009, 407).
The Clitoris and Sexual Function and Satisfaction
The final sentence of DeLaet’s analysis may strike a Western reader
as dubious. Is it not the case, this reader may be thinking, that female
circumcision at the very least involves the removal of the clitoris? And is
it not the case that—setting aside certain extremes such as subincision in
Aboriginal Australia or septic circumcisions among the Xhosa of South
Africa—male circumcision involves “only” the removal of the foreskin,
thereby leaving the rest of the organ intact? And does not this basic
anatomical difference suggest that, holding everything else to one side,
female circumcision is likely to be much more sexually damaging?
This appears to be a very common view. As David Johnson (1994)
has argued, “The circumcision of women is qualitatively different from
the circumcision of men. [It] takes from women an essential part of their
humanness, preventing them from ever becoming full participants in sexual
relations. In this sense, the male equivalent of female circumcision is not
circumcision but castration” (440). Nan Burke (1994) has expressed a
similar perspective: “the comparison to male circumcision is not apt and
belittles the seriousness of the debate. Unlike male circumcision, female
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circumcision is mutilation. The organ is destroyed and, along with it, any
pleasure the woman may experience during intercourse” (440).
Although both of these statements appear in a leading British healthcare
ethics journal, it is interesting to note that no citations were given for
any of the assertions made. Indeed, the authors may have thought that
no citations were necessary: perhaps they believed that they were simply
stating the obvious. However, recent research suggests that “the obvious”
may not be quite as obvious as has typically been presumed.
First, it is not the case that female circumcision necessarily involves
removal of the clitoris. Indeed, it is not the case that any form of female
circumcision removes the clitoris, because most of the clitoris is underneath
the skin. Anatomical studies show that the clitoris is a “multiplanar”
organ (O’Connell, Sanjeevan, and Hutson 2005) whose visible portion
varies considerably in size between individuals (roughly 1–3 centimeters in
the flaccid state), with the preponderance of its true length, including the
majority of its erectile tissue, being subcutaneous (Puppo 2013). There is
disagreement about whether internal clitoral structures can be stimulated
through the vagina—thereby allowing for a “vaginal orgasm” in some
women without recourse to external tissue (Fenner 2013; see also Ahmadu
and Shweder 2009; Paterson, Davis, and Binik 2012)—but it appears
likely that at least some of these structures can be activated even if the
“outside” part of the clitoris has been resected, by applying pressure to
the tissue that remains.
As Lucrezia Catania and her colleagues report, “[even in] infibulated
women, some fundamental structures for the orgasm have not been
excised.” Many infibulated women, therefore, “achieve orgasm by
stimulating the vagina and consider the clitoris as something extra” (2007,
1673). However, Catania et al. note that the term “clitoris” in this context
refers only to the visible, external part of the clitoris, which they describe as
the “tip of the iceberg” of the entire structure. Putting these observations
together, Shweder (2013) remarks that: “a massive amount of . . . tissue
and . . . nerve endings enabling the experience of sexual pleasure and the
capacity for orgasm reside beneath the surface of the vulva [and thus]
beyond the scope of any customary African circumcision procedure” (361;
see also Johnsdotter and Essén 2010; Lyons 2007).
None of this is to deny that the excision of sensitive genital tissue, damage
to or elimination of nerve endings, and the formation of scar tissue—all of
which occur in most forms of both female and male circumcision, as well as
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most forms of intersex genital “normalization” surgery—can increase the
risk of adverse sexual outcomes (for evidence concerning the female case,
see, e.g., Berg and Denison 2012; Paterson, Davis, and Binik 2012). For
one thing, as I have noted elsewhere, any sensation that would have been
experienced “in” the excised tissue itself is inevitably precluded by these
kinds of procedures (Earp 2016a, 2016b, 2016c); for another thing, any
associated feelings of loss or resentment—which are far from uncommon
in adults of all genders who were subjected to involuntary genital surgeries
in early childhood—can interfere with one’s sexual enjoyment quite apart
from any “purely physical” effects that may or may not ensue from the
act of cutting (Abdulcadir et al. 2010). But it is important to clarify that
the almost universal Western assumption regarding female genital cutting
in particular (at least its more invasive forms)—namely, that it eliminates
the capacity for orgasm as a matter of anatomical necessity—is simply
untrue.13 To the contrary, it appears that many, if not most, circumcised
women are capable of achieving orgasm, experiencing feelings of desire
and arousal, and enjoying their sexual experiences overall (Catania et al.
2007; Okonofua et al. 2002; Paterson, Davis, and Binik 2012; see also
Shweder 2013 for an overview and critical discussion). As Catania and
her co-authors point out:
Human sexuality depends on a complex interaction of cognitive processes,
relational dynamics, and neurophysiological and biochemical mechanisms.
It is influenced and modulated by many factors (biological, psychosexual,
and social/contextual dependence) which act in [such] a way that one factor
can improve or inhibit the other and vice versa. (2007, 1673)
In other words, the role of the clitoris in sexual function and satisfaction
is not biochemically determined (although it is certainly biochemically
influenced); instead, its role depends in large part upon “relational
dynamics” and “psychosexual” factors, including how a woman feels
about her own body in the context of her romantic partnerships and in
light of the prevailing sexual and aesthetic norms of her community.
For example, many African women see the external clitoris as an
undesirable “masculine” appendage, and prefer what they consider
to be a “smoother” and “neater” look, unencumbered by any fleshy
protrusions (Manderson 2004, 295; see also Ahmadu and Shweder 2009).
This perspective is captured by the blunt remark of one Somali woman,
who, after seeing surgically unmodified vulvae for the first time, stated:
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“I thought, they’ve got a lot of cow pussy. That’s what it looked like to
me. That part of a Somali woman is covered and closed—it looks better”
(quoted in Manderson 2004, 293). By removing parts of the vulva that
“stick out,” therefore, many of these women feel more beautiful, and
more confident in their own bodies, which can have a positive effect, all
else being equal, on their subjective sexual experience and satisfaction.
In this respect, they are not altogether unlike their Anglo–American
counterparts—increasingly teenage girls (see Braun 2010; BSPAG 2013)—
who opt for so-called “cosmetic” surgeries to achieve largely similar effects.
These surgeries, which I hasten to add are by no means unproblematic,
go variously by the names of “clitoral reshaping,” “clitoral unhooding,”
“labial trimming,” “vaginal rejuvenation,” “vaginal tightening,” “hymen
repair,” and other labels for “designer vaginas” (Green 2005; Liao,
Taghinejadi, and Creighton 2012; McColgan 2011; Rodriguez 2014).
As Ronán Conroy noted in a 2006 editorial in the BMJ, the practice of
nontherapeutic female genital alteration “is on the increase nowhere in the
world except in our so-called developed societies” (Conroy 2006, 106).
An Aside About Consent and Double Standards
That many of these Anglo–American females are teenagers is important.
This is because some people might think that the “African” customs
involving genital cutting are done exclusively to young girls (who cannot
provide their own informed consent), whereas the Western analogs are
done exclusively to adult women (who have requested them for “cosmetic”
reasons). But this is not accurate. In the first place, the large majority of
“African” genital cutting rites (whether done to females or males) are
performed around the time of puberty, and are in fact the very ritual by
which adult status is conferred within the community. In other words, by
the end of the ceremony, the initiate is in fact formally an adult—so the
question of whether she or he was competent to “consent” to the operation
is perhaps more complicated than these discussions typically allow. In the
Western context, by contrast, while it is true that most nontherapeutic
female (but not male) genital alterations are done to individuals over the
age of 18, evidence suggests that increasing numbers of those who undergo
such operations are aged 14 or even younger, having received permission
for the surgery from their parents (Liao, Taghinejadi, and Creighton 2012).
In my own view—for which I argue elsewhere (Carmack, Notini, and
Earp 2015; Earp 2012a, 2012b, 2013a, 2013b, 2014a, 2014b, 2014c,
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2015a, 2015b, 2015c, 2015d, 2015e, 2016a, 2016b, 2016c; Earp and
Darby 2015; Frisch and Earp 2016)—it is the case that all nontherapeutic
genital alterations, whether of females, males, or intersex people, and
regardless of their cultural background, should be performed (in Western
societies) only under conditions of informed consent as given by the
individual to be affected by the surgery. Here, however, I am merely
pointing out that the issue of childhood versus adulthood as a proxy for the
question of consent cannot be used as a bright-line means of distinguishing
so-called Western forms of nontherapeutic female genital cutting from so-
called African forms, in terms of actual contemporary practice.
Nor can supposed anatomical differences be used for this purpose.
Consider the following admission from the British government during its
deliberations over the “Prohibition of Female Circumcision Act” of 1985:
The problem is that while the distinction between this legitimate surgery
[i.e., Western female cosmetic genital surgery] and the traditional practice
of female circumcision is quite clear in commonsense terms, there is no
precise anatomical definition which would admit one and not the other.
(quoted in Dustin 2010, 15)
Notwithstanding this definitional problem, the British medical lobby were
apparently concerned14 that the government not make illegal a number of
quite popular and lucrative genital surgeries for British girls and women
who—as Moira Dustin (2010) puts it—were “under the misapprehension
that they had deformed genitalia” (15). The government’s solution was
as follows. First, they added a “mental health” exception for British girls,
who, as judged by their cosmetic surgeons, might be deemed to have such
“anxiety” about the shape or size of their external genitalia that it could
lead to “mental illness” (14). Second, they simultaneously blocked the
application of the mental illness clause to African immigrants who might
be distressed about (not) fitting in with the aesthetic norms of their own
communities:
In determining for the purposes of this section whether an action is necessary
for the mental health of a person, no account shall be taken of the effect on
that person of any belief on the part of that or any other person that the
operation is required as a matter of custom or ritual. (Quoted in Dustin 2010,
15; note that more recent 2003 legislation carries forward this distinction.)
In effect, the Act said that “if you are a British girl who believes her genitals
are abnormal, it is permissible to have surgery to fit in with the ideals of
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the majority society. However, if you are from a minority [community],
your mental health is culturally determined—you have a group delusion
rather than an individual one—and you do not have the same rights as
members of the majority society to alter your body” (Dustin 2010, 16;
see also McColgan 2011).15
African women have picked up on the double standard. As Nahid
Toubia—a Sudanese surgeon and longtime campaigner against FGM—has
cautioned: “The people of the countries where female genital mutilation
is practised resent references to ‘barbaric practices imposed on women
by male-dominated primitive societies,’ especially when they look at the
Western world and see women undergoing their own feminization rites
intended to increase sexual desirability: medically dangerous forms of
cosmetic plastic surgery, for instance” (Toubia 1995, as quoted in Sheldon
and Wilkinson 1998, 263–64). Indeed, as Isabel Gunning (1991) states,
“How bizarre and barbaric must a practice like implanting polyurethane
covered silicone into one’s breasts [i.e., breast augmentation surgery] be
perceived by one not accustomed to the practice” (213). As she goes on to
suggest, Westerners need to take seriously the fact that their “articulations
of concern over the contemporary practice of genital surgery in third world
nations are often perceived as only thinly disguised expressions of racial
and cultural superiority” (213)—calling to mind what Gayatri Spivak
(1988) once famously referred to as “white [people] seeking to save brown
women from brown men” (101).
Non-Clitoral Genital Cutting
Let us return to our discussion of the clitoris. One major lesson from
this discussion has been that the “symbolic meanings” of the clitoris are
different in different cultures. To many Western feminists, the clitoris
symbolizes both the liberation and embodiment of female sexuality: such
a view may have its origins in a particular discourse from the 1960s in
England and America concerning whether or not sex was equivalent to
penile penetration (see, e.g., Lyons 2007). To many African women, by
contrast, the external clitoris has a different significance: it is a vestige of
childhood androgyny—a “male” part whose removal is both feminizing
and an affirmation of “matriarchal power” (Ahmadu and Shweder 2009,
14; see also Shell-Duncan and Hernlund 2000, 21). There are many
other interpretations as well. Associations can be both conscious and
unconscious; they can (and do) overlap and change over time; and there
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is also significant variability in terms of how the clitoris is conceptualized
by different women even “within” a certain group or society (Shell-
Duncan and Hernlund 2000). The “meaning” of the clitoris, therefore,
is not strictly determined by its anatomical properties; women’s sexual
experiences cannot be meaningfully reduced to a tally of nerve endings
(Althof et al. 2005; Paterson, Davis, and Binik 2012).
Moreover, there are several kinds of female circumcision that do not
involve modification of the clitoris at all. Just as with the kinds that do,
however, these have been banned in many Western countries, as well as
defined as “mutilations” by the WHO/UN. For example, there is cutting or
removal of the clitoral hood, which is the skin that covers and protects the
head of the clitoris (much as the foreskin covers and protects the head of the
penis, see Cold and Taylor 1999). This is classified as FGM Type 1-a, and
it is anatomically identical to the Western “cosmetic” practice of clitoral
unhooding that I mentioned earlier. There is also cutting or removal of the
labia minora, which are the inner “lips” that frame the vaginal opening.
This is classified as FGM Type 2-a, and it is anatomically identical to the
Western “cosmetic” practice of labial trimming that I mentioned earlier.
For FGM Type 3, which is the narrowing or stitching of the vaginal
opening (infibulation), the WHO/UN note that this can be done with or
without the excision of the external clitoris. According to the available
empirical research on the question, it is frequently done without (see, e.g.,
Nour, Michels, and Bryant 2006). Although this is generally considered to
be the most “extreme” type of FGM, even here there are some apparent
Western parallels. For example, when a Western woman requests a “vaginal
tightening” procedure, perhaps after giving birth, this is not generally
considered to be a kind of FGM, even though it formally meets the
definition of infibulation. Instead, the procedure is referred to as “vaginal
rejuvenation” (see, e.g., Goodman 2009; see also Manderson 2004, 297).
When an African immigrant, by contrast, asks to be re-infibulated after she
has given birth—in order to “restore” her genitals to what she considers
to be their “normal” state—in England and Australia, at least, she will
be denied the procedure.16
Finally, FGM Type 4 is a catch-all category that refers to “all other
harmful procedures to the female genitalia for nonmedical purposes, for
example, pricking, piercing, incising, scraping, and cauterization” (WHO/
UN 2008, 24). Note that none of these involve the removal of the external
clitoris. Moreover, specific procedures like piercing—for example, of the
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labia or the clitoral hood—are also common in some Western countries, but
are considered in those contexts to be a form of cosmetic “enhancement”
(see, e.g., Armstrong, Caliendo, and Roberts 2006; Miller and Edenholm
1999).
Abstract Definitions, or Reality?
It is sometimes argued that the WHO classification scheme is somewhat
artificial. In other words, while it might describe interventions that are
anatomically possible, not all such interventions are reflective of “actual”
female circumcision as it is practiced “in the real world.” For example,
consider this email from a Norwegian medical anthropologist who worked
on the WHO/UN policy on FGM (personal correspondence, June 5th,
2014):
Type I, as you [point out], has a subtype of removal of [the] clitoral prepuce,
however, this is an anatomical definition. That is, if somebody were to
remove the foreskin of the clitoris, this would fall under Type I. However,
there is no traditional form of FGM that remove[s] the prepuce only, as
such a surgery would have to be carried out by a specialist surgeon under
full sedation.
Note that my correspondent refers to “traditional” circumcision in this
email, by which she apparently means circumcision that is not carried out
by a “specialist surgeon under full sedation.” However, as the WHO/UN
themselves report, “in some countries, one-third or more of women had
their daughter subjected to the practice by a trained health professional . . .
Evidence also shows that the trend is increasing in a number of countries”
(WHO/UN 2008, 12). While it is unclear how many of these cases involve
the removal of at least some portion of the clitoral hood, there is ample
evidence of interventions that are even less invasive than this being carried
out in a hospital setting. For example, in parts of Indonesia, Malaysia,
and in some other Muslim communities, the most common form of female
circumcision involves “nicking the clitoris [or clitoral hood] with a sharp
instrument to cause bleeding but no permanent alteration of the external
genitalia” (Shell-Duncan and Hernlund 2000, 5). As A. Rashid and
colleagues report, “a hospital based study in Malaysia has shown FGM
to be a common practice among the Malays but with no clinical evidence
of injury to the clitoris or the labia and no physical sign of excised tissue”
(Rashid, Patil, and Valimalar 2010, no page numbers; referring to Isa,
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Shuib and Othman 1999). However, the WHO/UN do not tolerate such
procedures, nor do they welcome the trend toward “medicalization”:
according to the WHO/UN, “Trained health professionals who perform
female genital mutilation are violating girls’ and women’s right to life, right
to physical integrity, and right to health” (WHO/UN 2008, 12) regardless
of the severity of the procedure (see also Askew et al. 2016).
Ritual “nicking” is increasingly common in immigrant communities
as well. In 1996, for example, several women from the large Somali
community in Seattle asked their doctors at Harborview Medical Center
if they would agree to perform the procedure on their daughters—along
with circumcision for their sons—as a replacement for the more invasive
rite that was likely to be carried out “either on a return trip to Somalia
or by Somali midwives in the United States” (Shell-Duncan and Hernlund
2000, 5). According to Doriane Coleman (1998), “the hospital initially
declined the request, telling the women that in this country only boys are
circumcised” (740). However, “the immigrants were . . . candid about
their commitment to practice some version of the procedure despite”
the U.S. law which prohibits all forms of FGM. For in their view, “the
procedure [was] necessary, both as a cultural matter [and] as a religious
matter because the oral teachings of their clerics require it” (741; see also
Arora and Jacobs 2016).
The doctors eventually agreed to do the procedure, reasoning that a
“symbolic nick” would be much less harmful to the girls than what they
were likely to be exposed to otherwise. When news of the decision leaked
out, however, the hospital was suddenly “besieged by outraged opponents
of female circumcision” (quoted in Coleman 1998, 745) who sent “hate
mail and death threats” to the doctors “for weeks” (748). Thus, “although
the so-called Seattle compromise would have involved no removal of tissue
and would have been performed under anesthesia on girls having given
consent, the plan was blocked by intense lobbying from anti-FGM activists
as well as by an outpouring of negative public opinion” (Shell-Duncan
and Hernlund 2000, 6).
Once again, the African parents were perplexed. As Ylva Hernlund and
Bettina Shell-Duncan (2007) report: “In a private conversation later with
two of the Somali women, who labeled themselves not only as refugees but
also as social service providers in another city, they talked at length about
this politically charged situation. It had not occurred to these extremely
bright, articulate, and politically astute women professionals that a simple
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pinprick of the clitoris could be illegal under U.S. law, while their own
sons legally underwent much more invasive procedures [i.e., routine male
circumcision]” (17–18).17
Explaining the Different Perceptions
Given everything that has been said so far, how might we begin to
explain the very different perceptions that Westerners seem to have when
it comes to female genital “mutilation” (on the one hand) and (on the
other hand) both female genital “cosmetic” surgeries and male forms
of nontherapeutic genital alteration? One possibility, mentioned earlier,
is that Westerners are simply more familiar with these latter kinds of
surgeries, such that they don’t seem quite so strange and barbaric (DeLaet
2009; Johnson 2010). As I have written elsewhere about the comparison
between FGM and male circumcision, when Westerners speak of “FGM,”
they are apparently calling to mind primarily “the most severe forms of
female genital cutting, done in the least sterile environments, with the
most drastic consequences likeliest to follow.” When people speak of
“male circumcision,” by contrast, they appear instead to be thinking of
“the least severe forms of male genital cutting, done in the most sterile
environments, with the least drastic consequences likeliest to follow.” This
then leads to the intuitive impression “that ‘FGM’ and ‘male circumcision’
are ‘totally different’ with the first being barbaric and crippling, and the
latter being benign or even health-conferring” (Earp 2014a; see also Earp
2015a, 2015d). However, as Androus (2004) has pointed out, there is a
fatal flaw in this “Western” way of thinking:
This attitude that male circumcision is harmless [happens to be] consistent
with Western cultural values and practices, while any such procedures
performed on girls [are] totally alien to Western cultural values. [However]
the fact of the matter is that what’s done to some girls [in some cultures]
is worse than what’s done to some boys, and what’s done to some boys [in
some cultures] is worse than what’s done to some girls. By collapsing all of
the many different types of procedures performed into a single set for each
sex, categories are created that do not accurately describe any situation that
actually occurs anywhere in the world. (3)
Moreover, as Toubia (1999)—the Sudanese surgeon and women’s health
advocate—has pointed out, there is a significant power differential to
consider as well:
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A major difference between male and female circumcision is that the female
procedure is primarily carried out in Africa, which is currently the least
dominant culture in the world. The male procedure is also common in the
same countries, but it is also common in the United States, which is currently
the most dominant culture in the world through its far-reaching media
machine. This historical situation has made it easier to vilify and condemn
what is common in Africa and sanctify what is popular in America. (5)
We can now bring our analysis back to the policy of the WHO/UN on
FGM as presented earlier. As critics have pointed out, while the WHO,
UN, and other such organizations are nominally global in their scope
and constitution—as opposed to being explicitly Western—there is also a
significant asymmetry in terms of the actual “bargaining power” between
the Western and non-Western nations. To use a different terminology,
a great deal more power is held by the so-called “rich nations of the
[global] North” (including the United States)—where FGM is not
customarily performed—and a great deal less power is held by the so-
called “poor nations of the [global] South,” where, in many communities,
it is performed, and is deeply embedded in the local context (Shweder
2005, 185). Thus, this argument runs, the “consensus” statements of
such “global” authorities may not reflect a genuine consensus, but rather
the particular norms and values, or even idiosyncratic cultural traditions
that happen to be comparatively popular in the more powerful nations.
As Shweder (2005) has suggested: “[the] rules of the cultural correctness
game have been ‘fixed’ [by] First World” institutions (185).
A similar perspective has been advanced by Abdullahi Ahmed An-Na’im
(1995; quoted in Harris-Short 2003): “Western hegemony . . . profoundly
influences ruling elites, as well as scholars and activists in the South or the
Third World,” he writes, such that “it is misleading to assume genuine
representation of popular perceptions and attitudes toward human rights
in our countries from the formal participation of ‘our delegates’ [in]
international fora” (133).
RETURNING TO THE WHO/UN POSITION
It should be clear by now that I am sympathetic with this view. Indeed, I
do not think that the WHO/UN position reflects truly universal values (for
a general discussion, see Mutua 2004); and to the extent that the values it
does reflect happen to have been formulated in terms of universal moral
principles, I do not think that such principles are being consistently applied.
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The WHO/UN position, recall, is that all forms of FGM are morally
impermissible. This is deemed to be the case regardless of the type or extent
of the intervention, regardless of the cultural or even clinical context,
and notwithstanding anyone’s beliefs to the contrary. As the WHO/UN
(2008) state explicitly: “Female genital mutilation of any type has been
recognized as a harmful practice and a violation of the human rights of
girls and women” (8). This is a strong position. How do the WHO/UN
defend it? There seem to be three main strands to their argument:
(i) The harm strand. This strand suggests that FGM is harmful to
health, harmful to sexuality, and harmful to overall well-being.
(ii) The discrimination strand. This strand suggests that—even if
the harms of FGM could somehow be minimized—it would still
constitute “an extreme form of discrimination against women” (1)
because it is a “manifestation of gender inequality” (15).
(iii) The rights strand. This strand suggests that FGM is a violation
of “fundamental human rights.” For example, it is a violation of the
“right to . . . physical integrity” (1). Moreover, since it “is nearly
always carried out on minors” who cannot provide consent, it is also
“a violation of the rights of the child” (1).
Obviously, these strands are not entirely distinct. For example, the
discrimination strand overlaps with the rights strand since the WHO/UN
argue that FGM violates the human rights principle of “non-discrimination
on the basis of sex” (2008, 9). The harm strand might overlap with the
rights strand as well: as Shweder (2005) notes, “If [FGM] is a harmful
practice and you are prepared to defend the idea that there are natural,
objective, or inalienable rights . . . then it is but a small step to include the
right to be free from physical and psychological harm as a basic human
right” (186). And finally, the discrimination strand and the harm strand
could be seen as overlapping as well: surely, being discriminated against
on the basis of one’s sex could be psychologically harmful, at least, and,
depending upon the particular manifestation of the discrimination, perhaps
harmful to health, etc., as well.
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Harm
Let us start by looking at the harm strand. According to the WHO/
UN (2008):
Female genital mutilation has no known health benefits. On the contrary, it is
known to be harmful to girls and women in many ways. First and foremost,
it is painful and traumatic. The removal of or damage to healthy, normal
genital tissue interferes with the natural functioning of the body and causes
several immediate and long-term health consequences. (1)
I contend that this harm argument—certainly on its own—is far from
sufficient to establish that all forms of FGM are impermissible regardless
of the cultural context; and I suggest, moreover, that the WHO/UN are
applying this argument in an inconsistent manner. I will take the above
sub-claims out of order, and analyze them one by one.
First—it is not the case that all forms of FGM are “painful and
traumatic,” at least not in a way that is particularly morally meaningful.
Minor forms of FGM (such as “pricking”) that are carried out with
anesthesia—as is increasingly being done in a range of contexts (see
above)—are no more painful than any number of experiences that a child
or adult is likely to experience in the course of daily living (although such
“pricking” may of course be psychologically disturbing, depending upon
how it is carried out, at what age, whether there is cooperation from the
individual, what her attitudes are toward the procedure, and so on). On
the other hand, some forms of FGM are extremely painful, and seem to
be experienced as profoundly traumatic on any recognizable conception
of that term. I am inclined to think that at least some such forms may be
impermissible regardless of the cultural context—particularly if they are
carried out on children, for reasons I will soon explain.
But I also recognize that the experience of even extreme pain is not
necessarily interpreted in the same way in every culture (or by every
individual). Sometimes pain can have instrumental value; for example, in
some groups, such as the Rendille of Kenya, “women reject the idea of
using anesthesia when being excised and instead emphasize the importance
of being able to withstand the pain of being cut as preparation for enduring
the pain of childbirth and as demonstrating maturity” (Shell-Duncan and
Hernlund 2000, 16). As Lyons (2007) notes, “The opportunity to gain
social status by a demonstration of courage and endurance in the face of
physical suffering has been cited by many writers [as] an important part
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of the positive value associated with female and male initiation rituals,
cross-culturally” (6). At the same time, however, in Europe and North
America, there appears to be a pervasive assumption that only boys and
men should have to tolerate painful experiences as a way of showing
courage, “particularly in connection with warfare and sports” (6). This
may be part of the reason, Lyons suggests, that painful rituals undergone
by males, compared to females, provoke less of a reaction of repugnance in
most Westerners. Consistent with this view, as Shell-Duncan and Hernlund
(2000) note, “there appears to exist in the West a tolerance of, and perhaps
appreciation for, the assumption that masculine ideals are honed through
painful initiations that respond to group needs” (16).
Similar to the Rendille women of Kenya, adolescent males in some
groups who undergo painful initiation rites look down on anesthesia as
well. As the account by Nelson Mandela I quoted from earlier illustrates,
boys may be expected to “suffer in silence” as their foreskins are cut off,
despite the agonizing pain that is involved. Indeed, these rites are, among
other things, designed to be tests of masculinity: the pain is part of the
point (see, e.g., James 2005). Now, whether such painful rites or rituals
can possibly be justified on moral grounds, or under what conditions, is
a complicated question, but the question in this case does not arise. This
is because it is clear that the WHO/UN do not regard the experience
of extreme pain and/or trauma as being sufficient to justify a universal
prohibition on genital cutting, since they have taken no position on male
circumcision, including its most excruciating forms.
A similar analysis applies to the claim that “the removal of or damage to
healthy, normal genital tissue interferes with the natural functioning of the
body and causes several immediate and long-term health consequences.”
Some forms of FGM do not remove healthy, normal genital tissue (for
example, pricking or piercing); and if they are performed in a superficial
enough manner, it is not clear in what sense they could be said to be
“damaging” to the genitals either. Nevertheless, even these “minor”
forms of FGM are seen as impermissible by the WHO/UN, including in
medicalized cases where both immediate and long-term (adverse) health
consequences would be comparatively unlikely to ensue. By contrast, even
the most minor—and widespread—forms of male circumcision typically
entail the removal of the adult equivalent of up to 100 square centimeters
of “healthy, normal genital tissue,” with mean reported values for foreskin
surface area ranging from about 30 to 50 square centimeters (see Kigozi et
al. 2009; Werker, Terng, and Kon 1998). To remove such a large quantity
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of “healthy, normal genital tissue” necessarily “interferes with the natural
functioning of the body.” For example, it interferes with (eliminates) the
protective functions of the foreskin (exposing the head of the penis to
irritants from the environment, such as urine and feces in the diapers of the
youngest of boys, and to rubbing against clothing thereafter; see, e.g., Still
1972); it also interferes with (eliminates) all sexual functions and related
erotic activities that involve manipulation of the foreskin itself (see Ball
2006; Earp 2015c, 2016a, 2016b, 2016c; Frisch and Earp 2016; see also
Harrison 2002 re: “docking”).
Likewise, female genital “cosmetic” surgeries that are popular in
Western countries—such as labiaplasty or clitoral reshaping—certainly
“remove healthy and normal genital tissue,” and also carry a nontrivial
risk of “immediate and long-term health consequences” (BSPAG 2013).
Nevertheless, the WHO/UN have not taken a position on either of these
latter surgeries, suggesting that it is not the mere interference with “healthy,
normal genital tissue,” nor the presence of some degree of risk of adverse
health consequences that they see as being sufficient to justify a universal
prohibition on FGM.
The claim that “female genital mutilation has no known health benefits”
is very interesting. First, this claim was evidently inserted as a point of
specific contrast with male circumcision, which is mentioned at least once
in WHO/UN (2008) statement, as follows:
In contrast to female genital mutilation, male circumcision has significant
health benefits that outweigh the very low risk of complications when
performed by adequately-equipped and well-trained providers in hygienic
settings. Circumcision has been shown to lower men’s risk for HIV
acquisition by about 60% . . . and is now recognized as an additional
intervention to reduce infection in men in settings where there is a high
prevalence of HIV. (11)
Several points are worth mentioning here. First, the WHO/UN in this
passage are very careful to qualify just what kind of male circumcision
they have in mind—which is the specific kind that happens to be popular
in the United States, and, if not popular in other Western countries, at
least familiar: namely, “medicalized” male circumcision such as might be
carried out in a clinic or a hospital (see, e.g., Carpenter 2010; see also
Bell 2015; however note that the U.S. version of the surgery is typically
carried out on infants, for which there is currently no controlled evidence
of a protective effect against subsequent acquisition of HIV, whereas the
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data concerning HIV protection in Africa were derived from circumcisions
performed on adult volunteers; for further discussion, see Bossio, Pukall,
and Steele 2014). This is in contrast to (a) the WHO/UN’s comparative
silence on male circumcision as it is performed in so-called “traditional”
settings in Africa and elsewhere, where it is done, as I have suggested,
under similar conditions to FGM, in the same communities, and for similar
reasons—often with comparable or even much more severe adverse health
consequences (as illustrated by the example of the Xhosa of South Africa
between 2008 and 2014), and (b) the WHO/UN’s systematic conflation of
the most extreme types of FGM with the comparatively minor, medicalized,
and anaesthetized versions of the procedure that are common in many
places around the world.
Thus, when the WHO/UN refer to FGM, they choose to describe only
negative effects that have been associated with the most extreme and
unhygienic forms of female genital cutting—and then they present these
as being typical of all forms of female genital cutting. When they refer to
“male circumcision,” by contrast, they choose to describe only positive
effects that have been associated with the most minor and hygienic forms
of male genital cutting—and then they present these as being typical of all
forms of male genital cutting.18 This is consistent with the view I presented
earlier concerning the very different “prototypes” that many people seem
to have in mind when they think about male vs. female forms of genital
cutting.
There is much more that could be said about the “health benefits” claim
regarding male circumcision, and about the claimed lack of such benefits
in the case of female genital cutting, but there is not adequate room to
address these matters here. Suffice it to say that it is far from clear that
nontherapeutic genital cutting can be categorically distinguished on the
basis of sex by an appeal to health benefits. For a brief introduction, see
this endnote.19
Discrimination
Now let us turn to the question of discrimination. As the WHO/UN
(2008) state:
In every society in which it is practised, female genital mutilation is a
manifestation of gender inequality that is deeply entrenched in social,
economic and political structures. Like the now-abandoned foot-binding
in China and the practice of dowry and child marriage, female genital
mutilation represents society’s control over women. Such practices have the
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effect of perpetuating normative gender roles that are unequal and harm
women. (5)
On what basis do the WHO/UN advance this thesis? Certainly, it cannot be
deduced from the work of the anthropologists they cite in their references
section, several of whom have gone to great lengths in recent years to
challenge the very perspective that is summarized in the quote above. For
example, they cite a well-known paper by Fuambai Ahmadu (2000), the
Sierra Leonean–American anthropologist I referred to earlier, who chose
to be circumcised as an adult through the Bondo women’s secret society
of her native Kono ethnic group. As she writes:
I [share] with feminist scholars and activists campaigning against the practice
a concern for women’s physical, psychological, and sexual well-being, as
well as for the implications of these traditional rituals for women’s status
and power in society. Coming from an ethnic group in which female (and
male) initiation and “circumcision” are institutionalized . . . and having
myself undergone this traditional process of becoming a “woman,” I find
it increasingly hard to reconcile my own experiences with prevailing global
discourses on female “circumcision.” (283)
For example, contrary to the view that female genital-altering rituals
necessarily represent “society’s control over women” (and what does that
mean?)—or that they are always associated with “unequal gender roles,”
Ahmadu (2000) argues that:
Among the Kono there is no cultural obsession with feminine chastity,
virginity, or women’s sexual fidelity, perhaps because the role of the
biological father is considered marginal and peripheral to the central
“matricentric unit.” . . . Kono culture promulgates a dual-sex ideology, which
is manifested in political and social organizations, sexual division of labor,
and notably, the presence of powerful female and male secret societies. The
existence and power of Bundu, the women’s secret sodality, suggest positive
links between excision, women’s religious ideology, their power in domestic
relations, and their high profile in the “public arena.” (285)
There are of course “normative gender roles” among the Kono in Sierra
Leone. But then, there are normative gender roles in every society, including
in Western countries. What Ahmadu seems to be arguing is, first, that
the role/status associated with being a woman in Kono society is not
necessarily “lower” than the role/status associated with being a man,
and, second, that Kono genital-altering rites are not “unequal” in a way
that is necessarily harmful to women. Instead, since both girls and boys
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are initiated into Kono secret societies, the rites are at least superficially
egalitarian; and, at least as concerns the female version, to Ahmadu they
are also empowering.
The WHO/UN also cite the work of Lori Leonard. Leonard has done
groundbreaking work with the Sara ethnic group in Chad, where she
noticed a “disjoint” between the portrayals of female genital cutting in
the mainstream Western literature and the “stories told in Sara villages”
(2000, 170–71). This disjoint “highlighted the narrow spectrum covered
by existing interpretations, as well as the dearth of alternative stories
of female genital cutting currently circulating” in the Western discourse
(ibid.). For example, among the Sara,
Village residents uniformly report that the impetus for the adoption of female
genital cutting has come from adolescent girls, who organize the ceremonies,
obtain the resources required to participate . . . and find and “hire” the
excisor. Village authorities, traditional leaders, and parents are not involved
in the planning or execution of female genital cutting ceremonies, and with
few exceptions, are vocal in their opposition to the practice. [The] supreme
religious and spiritual leader [of the community] has forbidden girls to get
cut, has levied fines against those who do it, and has refused to attend the
dances that are part of the girls’ coming-out ceremonies. . . . Mothers, none
of whom have been cut, are not allowed to participate in the ceremonies,
and in general, they neither understand nor support the decisions of their
daughters. (174)
For their part, the daughters “describe their participation as entirely
voluntary.” When asked why they chose to participate, “girls underscored
their sense of agency, saying ‘it was my will,’ and [that] the cutting
ceremonies were ‘something that interested me’” (175).
It is unclear how the situation described by Leonard could reasonably
be interpreted as an example of “society controlling women” based
on “unequal” and “harmful” gender roles. Indeed, on the basis of her
experience with the Sara, Leonard explicitly recommends against the
“application of grand narratives or over-arching theories” (185) in trying
to explain the great diversity of female genital-altering rituals that exist
in different societies. She suggests, rather, that such rituals need to be
understood on the basis of immersion in the local context—not based on
an “advocacy” agenda whose very premise is to eliminate such rites. Yet
this is precisely the agenda and the premise that have been adopted by
the WHO/UN.20
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Rights
Finally, let us turn to the question of rights. Here, I think that the
WHO/UN are on the strongest footing for suggesting that all forms of
FGM are impermissible. For, if there is such a thing as a “right to physical
integrity,” then even the most minor, sterilized, anesthetized “prick” might
be considered to violate such a right.
However, it is a bit more complicated than that. Consider the case of an
adult African woman such as Fuambai Ahmadu. Ahmadu was educated
in the West—with a PhD from the London School of Economics—and
also felt deeply connected to her Kono ethnic heritage. When she was 21,
she traveled to Sierra Leone, and—by all appearances—chose to undergo
female circumcision (or “mutilation” in the language of the WHO/UN).
The WHO/UN (2008) however, do not distinguish between adult women
and minor girls in their analysis. Instead, FGM refers to “all procedures
involving partial or total removal of the external female genitalia . . . for
non-medical reasons” (1).
How might one explain this position? If one considers, first, the theory
of the WHO/UN (2008) that FGM of any type is harmful, and, second,
if one considers their assumption that FGM is always linked to “control
over women” (5), then perhaps the idea is that even adult women cannot
provide genuine consent when it comes to making certain decisions about
their own genitals. I find this assumption to be extremely implausible, but
let us just assume it is true. If it is true, then the WHO/UN would need
to explain why they have not launched any campaigns to “eliminate”
so-called female genital cosmetic surgeries—technically FGM according
to the WHO/UN definitions—as they are practiced in Western societies.
In fact, if one looks to the Appendix of the WHO/UN (2008) report, and
turns to a small sub-section entitled, “Further Considerations,” one finds
an interesting clue:
Some practices, such as genital cosmetic surgery and hymen repair, which are
legally accepted in many countries and not generally considered to constitute
female genital mutilation, actually fall under the definition[s] used here. It
has been considered important, however, to maintain a broad definition of
female genital mutilation in order to avoid loopholes that might allow the
practice to continue. (28)
By “the practice,” the WHO/UN evidently mean, “the practice as it is
performed in non-Western countries.” One is reminded of the dilemma
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faced by the British government in 1985: how can one craft language
that allows for genital-altering surgeries that are popular among Western
women (for “enhancement” reasons), but that simultaneously disallows
genital-altering surgeries that are popular among African women (for
“cultural” reasons)? How can one do so, moreover, despite the fact that
there is no anatomically objective line that can be drawn between them, nor
very likely a principled way to distinguish one woman’s “enhancement”
from another one’s “culture”? The WHO/UN strategy, apparently, has
been to adopt a “broad” definition that does not permit any “loopholes”
through which an “African” practice might slip through, while simply
declining to enforce their own definitions in Western countries (except in
the case of African and/or Muslim immigrants in such countries, in which
case the definitions are treated as valid; see Dustin 2010).
Children
What about when it comes to children? Do children have a “right”
to “physical integrity” that is necessarily violated by all forms of genital
alteration that are performed for nontherapeutic reasons? If so, then we
could confidently conclude that—at least before an age of adulthood or
consent—all forms of FGM really are impermissible, including (possibly)
even across cultures. Of course, all forms of nontherapeutic male and
intersex genital cutting would also have to be deemed to be impermissible
(before an age of consent) on these grounds, because all such interventions
also involve the “violation” of a child’s “physical integrity.” Indeed,
as noted earlier, I am sympathetic with this view, and I have argued
that medically unnecessary alteration of children’s genitals should be
discouraged, regardless of the sex or gender of the child, at least in the
context of the societies with whose legal, moral, and cultural environments
I am most familiar (i.e., England, the United States, and similar). In other
words, since even the most minor forms of FGM—such as a “prick” to the
clitoral hood—are impermissible according to the WHO/UN, and since, on
the WHO/UN’s own theory of fundamental human rights, discrimination
on the basis of sex is impermissible, it would not be morally defensible to
adopt a sexist double standard in the analysis of children’s “basic rights”
with respect to preservation of their physical integrity.
However, there is a prior question here. Namely: do children, in fact,
have a right to physical integrity that could reasonably be construed as
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being violated by even the most minimal forms of FGM as defined by the
WHO/UN?
Let us dispose of a potential red herring. It cannot be the case that the
WHO/UN regard a child’s physical integrity as being absolutely inviolable.
We know this because the WHO/UN make an exception, in their definition
of FGM, for so-called “medical reasons.” On this view, if there is a
valid medical reason to “partially or totally remove the external female
genitalia” or to cause “injury to the female genital organs,” then such an
intervention would not count as a form of mutilation—i.e., something that
is bad by definition—but could rather be considered permissible. Thus,
according to the WHO/UN, it may at least sometimes be permissible (or
even desirable) to “violate a child’s physical integrity,” namely, if there is
a “medical reason” for doing so.
As Shweder (2013) has written, “One hesitates to engage in a full
blown semantic analysis of the meaning of the word ‘medical’ . . . [but]
narrowly speaking, medical means doing things to the body aimed at
preventing, alleviating or curing a disease or functional disability” (35).
The problem is, what is a “disease”? And what is a “functional disability”?
It is well known that there is no particular consensus about the meaning
or referents of these words, even within so-called Western medicine (see
generally, Rosenberg and Golden 1992)—so it is unlikely that there could
be a universal consensus about their meanings that would apply to every
culture.
But let us try to illustrate this idea—about “disease”—using a Western
example (though one that is by no means exclusive to the West) that should
be fairly intuitive in this discourse. Let us say that a child has gangrene on
her leg due to a bacterial infection. The leg is beginning to rot; the infection
is spreading up her limb. Most people—and on this occasion, although
I am not an anthropologist, I think it would be fair to say “most people,
in every culture”—would say that it is permissible to infringe upon the
child’s physical integrity in order to saw off the infected limb, before the
infection spread to other parts of the body. I assume that the reason such
a violation is seen as being permissible is because it is presumed to be in
the best interests of the child, where “best interests” is taken to mean,
“most conducive to the child’s overall well-being, all things considered.”21
Since in this case, it would not be possible to delay the intervention until
the child reached an age of consent (and could therefore give permission
for her physical integrity to be “violated” on the basis of her own judgment
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about what would best promote her well-being) without actually sacrificing
the very thing about the intervention that would make it in her best interests
in the first place, it is clear that performing the intervention prior to the
possibility of obtaining the child’s consent is permissible.
If that much is right, then it seems to me that the ultimate moral goal
in this case is not so much to “treat disease” with “medicine” (per se), but
rather to promote the child’s overall well-being, all things considered. If
so, then it would not be the case that something’s being “medicine” (or
not) is morally decisive in and of itself, but rather its being instrumental
in some way to promoting the—overriding—goal of advancing the child’s
best interests. If something is instrumental in this way, then I propose that
it should be called an enhancement.
Enhancement
In this section, I am going to argue that it should be considered
permissible, all else being equal,22 for parents to “enhance” their children
in the sense I have just described. Just to be clear, and to put it another
way, what I mean by the word “enhance” is: “make decisions that are
instrumental to the promotion of their child’s overall well-being, all things
considered” (for further discussion of this argument, and to see how it
fits in with the wider “enhancement” debate in biomedical ethics, please
see Earp et al. 2014, and Maslen et al. 2014).
A couple of observations can now be made. First, I assume that this is
a principle that really every culture would endorse. That is, I assume that
most well-informed, rational people around the world, regardless of their
particular cultural background, would agree that parents should be able
to “enhance” their children in the sense I have defined. If this principle is
ultimately seen as being valid, therefore, it would not be subject to charges
of cultural imperialism, and that seems to be a quality worth striving for.
Second, I think that such a principle is better at capturing commonsense
moral intuitions—at least compared to the WHO/UN’s “medical reasons”
principle—concerning when it might be permissible to “violate the physical
integrity” of a child. Consider the use of orthodontics to straighten a young
person’s teeth—for “cosmetic” reasons, let us say, rather than strictly
“medical” ones (i.e., reasons aimed at maintaining or restoring some
straightforward function, such as the ability to effectively chew food).
While braces do not actually remove any tissue from the child’s body
(and while that is a relevant moral consideration, as we shall see), they do
certainly alter the child’s body, and as some might argue, in a somewhat
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serious and invasive way. Moreover, braces are painful; they carry certain
risks (of, e.g., infection); their effects are, for all intents and purposes,
irreversible; and they are put on, in most cases in Western societies, before
an age of legal majority.23 Yet if it is only permissible to “violate a child’s
physical integrity” for “medical reasons”—as I have suggested is implied
by the position of the WHO/UN—then we would have to conclude that
cosmetic orthodontics are not permissible for children, even though (I take
it) most people would be inclined to say that they are.
It seems, therefore, that the WHO/UN’s moral principle that I suggested
had the most promise for being able to justify the assertion that all forms
of FGM are impermissible (namely, that it is not permissible to “violate
the physical integrity” of a child except for “medical reasons”) actually
does not stand up to scrutiny. For, when such a principle is applied to a
common Western practice that, as I see it, is clearly permissible, it seems
to yield the conclusion that such a practice is not permissible, which
undermines the credibility of the theory.
Let us now try the principle I have suggested instead. I claim that it is
permissible (all else being equal) for parents to “enhance” their child(ren),
in the sense of making decisions that are in the child’s best interests—
whether or not the means of doing so happens to be in the medical domain.
According to this analysis, it seems that cosmetic orthodontics actually
would be properly considered to be morally permissible for children
(in most cases), notwithstanding the fact that they would infringe upon
the child’s physical integrity for plainly “nonmedical” reasons. Such
permissibility is especially likely to hold if the child actively desires or
requests the orthodontics (or can at least participate in the decision-making
process), as opposed to a situation in which the orthodontics had to be
forced upon an unwilling child despite sustained and well-considered
resistance (see Maslan et al. 2014 for a related argument about “hyper
parenting”).
This analsis rests on a number of partially interrelated factors: (i) the
widely-appreciated aesthetic improvement that comparatively straight teeth
are generally taken to represent; (ii) the associated social and psychological
advantages that typically go along with such perceived improvement; (iii)
the relative stability across time and space of the underlying perceptual
biases which give rise to the aesthetic preferences that confer such social
advantages; (iv) the fact that these perceptual biases, aesthetic preferences,
and associated norms do not appear to be, themselves, unjust (e.g., they
are not racist or sexist); (v) the very low risk of both “medical” and
Maslen
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“nonmedical” disadvantages associated with orthodontics (i.e., “trade-
offs” that might count against the intervention); and consequently (vi) the
lack of any indication that there is more than a handful of adults who feel
seriously harmed in virtue of having had braces when they were younger
(see Earp 2015a, 2015c). This last point is one to which we will return.
So what is the more general issue? To my mind, the key question here
is the following: How can we know whether a proposed enhancement
is in fact in the child’s best interests (and thus a true, rather than merely
intended, enhancement)—and who should be able to decide (see, e.g.,
Parens 2014, 147–48)? Clearly, some enhancements are more controversial
than others. Sending one’s child to school, for example, is obviously an
enhancement as I have defined it (even though some children would rather
stay at home and play); as is “forcing” one’s child to brush her teeth, eat
her vegetables, and so on, among many other examples that could be
imagined. By contrast, removing part(s) of a child’s genitals (whether the
child happens to be female, intersex, or male) for so-called cultural reasons,
or even for intended prophylaxis, is not quite so obviously in the child’s
best interests, considered from an impartial perspective. Indeed, even in
cultures (or sub-cultures) in which the retention of intact genitalia is for
the most part socially stigmatized, such tissue-removal is nevertheless the
source of frequent controversy and disagreement (Glick 2005; Goldman
1998; Gollaher 2000).
One reason why it is controversial is that, in a mundane sense, it involves
a physical trade-off or loss: healthy, functional tissue is (at minimum)
damaged, and (more typically) permanently excised, depending upon the
type of male or female circumcision. Whether this loss is “worth” the
purported gains in socio–cultural, religious, spiritual, or even prophylactic
benefits that supporters of male and female circumcision typically attribute
to them will depend upon numerous factors: how much value one places
on having intact genitals, how closely one identifies with the culture or
sub-culture in which one has been raised, and so on. In cases such as this,
that is, cases in which a proposed enhancement involves certain physical
or functional trade-offs—and especially when the overall value of such
trade-offs rests upon subjective norms and preferences that are highly
variable between cultures and individuals—it seems fair to suggest that the
intervention should ideally be delayed until such a time as the individual
who will be affected by it has the opportunity to make an informed
decision. As my colleagues and I have recently argued:
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Whilst adults are in a position to decide whether effect X is valuable enough
(to them) to justify incurring impairment Y, children do not yet have the
capacity or the life experience to make such trade-off decisions. They do
not know what they will value when they grow up and nor do their parents.
Whilst an intervention that improves X may count as an enhancement
for the individual who does not care much about Y, another individual,
valuing Y over X, will view the very same outcome as an impairment. In
such cases—that is, cases in which the very status of an intervention’s being
an (overall) enhancement vs. an impairment is controversial—the weight
of considerations should shift toward delaying the intervention until the
individual who will actually be affected by it has sufficient capacity to decide.
The more permanent and substantial the trade-off, the more this argument
has force. (Maslen et al. 2014, 4)
Applying the Argument to Genital Cutting
What does this argument suggest about the permissibility of FGM? The
answer to this question, it seems, must depend upon several factors. Is it
conceivable that at least some forms of “nonmedical” genital modification
performed on a female child or adolescent might turn out to be, in some
society, in the overall best interests of the child—and that this would be
uncontroversial enough, in that context, to fall under the purview of
reasonable parental decision making? As I have been learning from the
work of anthropologists such as Shweder, Ahmadu, and Leonard, societies
are very diverse, and the world is a complex place. Some societies might
be organized in ways that, without having been immersed in them myself,
I might not be in a position properly to evaluate. So it occurs to me that,
in some contexts, at least some forms of alteration to the female genitalia
(before an age of formal adulthood or ability-to-provide consent, as those
thresholds are reasonably understood in the relevant context, and without
some kind of urgent medical need) might be in the child’s best interests, and
that this might fall within the purview of appropriate parental judgment.
But several crucial variables are involved here. For instance, the more
tissue that is removed of a certain kind—specifically, tissue with properties
that are regarded as being valuable by a significant proportion of those
who are familiar with the tissue (for example, in virtue of retaining this
tissue on their own bodies)—the less likely it is that the intervention could
be considered to be in a girl’s overall best interests. To illustrate, removing
the entire external clitoris, compared to removing a small amount of tissue
from the labia majora, seems much more likely to be the sort of thing that
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a girl might later, upon gaining a different perspective (perhaps by moving
to a different society with different norms about genital aesthetics) turn
out very seriously to resent. Similarly, the more hygienic the circumstances
of the operation, the more likely it could be considered to be in the girl’s
best interests, and the less hygienic, the less. Finally, the more it is the case
that the intervention’s very status as being an enhancement (as opposed to
a diminishment, or even a mutilation) is contested or controversial in some
society, then the more it would be better to let the girl make a decision
about it herself, at a later age, when she could take into consideration the
fullness of her circumstances.
Importantly, on this last point, female, male, and intersex genital
cutting practices are becoming more contentious in more societies over
time (Dreger 2006; Gollaher 2000; Hernlund and Shell-Duncan 2007;
Svoboda 2013, 2015). Partly, this is due to the flow of information (and
people) through media, migration, and so on: individuals are less and
less likely to live in perfectly isolated communities, where the norms that
govern whether some intervention is widely seen as being an enhancement
in some context can be comparatively easily controlled (see Earp 2013b;
see also Hernlund and Shell-Duncan 2007). Referring to a community of
Somali immigrants in Sweden, for example, Sara Johnsdotter and Birgitta
Essén (2016) argue:
migration gives rise to cultural reflection: All the motives for [female]
circumcision in Somalia are turned [inside] out in exiled life in Sweden.
What was once largely seen as “normal” and “natural” about . . . cut
and sewn genitalia was questioned in Sweden, when the women were met
with shocked reactions among healthcare providers in maternal care and
delivery rooms. A thitherto strong conviction that circumcision of girls was
required by religion was questioned when Somalis met Arab Muslims, who
do not circumcise their daughters . . . . The fear that their daughters would
be rejected at marriage if uncircumcised disappeared in the light of the
immense Somali diaspora in the West, where Somali men can be expected
to accept and even appreciate uncircumcised wives. In addition, the risk of
stigmatization and ostracism disappeared when living in an environment
where most girls are not circumcised. (4)
Cultural change can happen in many ways, of course, and not always
through the mechanism of migration. Consider the case of infant male
circumcision in the United States (and to a lesser degree, Canada): this is
certainly a popular, if waning, birth custom in North American culture,
and many parents believe that they are enhancing their child’s genitals by
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authorizing the removal of his foreskin in the first few days after he is born.
They may believe that a circumcised penis is more aesthetically appealing,
for example, or that circumcision is necessary for proper hygiene (Rediger
and Muller 2013). Or they may think of the foreskin as a “useless flap of
skin” (Rabin 2009) that is prone to infection or other medical problems.
In light of these common assumptions, they may even believe that having
surgically modified genitalia is the “default” status for boys and men
throughout the West.
But now there is the Internet.24 Many American men, without having
to travel to other societies in order to gain a different perspective, are
learning that the U.S.’s habit of circumcision sets it apart from most of
its peer nations in the rest of the industrialized world (Morris et al. 2016;
Wallerstein 1985). They are finding out that European and Australasian
doctors, for instance, are for the most part unimpressed by the claims of
American doctors that circumcision has “health benefits” that “outweigh
the risks” (Forbes 2015; Frisch et al. 2013; Kupferschmid et al. 2015;
see also Earp and Darby 2015; Freedman 2016; Frisch and Earp 2016).
They are learning about the dubious establishment of male circumcision
as a “medicalized” procedure in the late 1800s (Aggleton 2007; Gollaher
2000), and are questioning how it came to be settled as a cultural norm.
They are finding out about the anatomy, innervation, and functions of
the foreskin, and about the ways in which these aspects may contribute
positively to sexual experience (see Ball 2006; Bossio, Pukall, and Bartley
2015; Cold and Taylor 1999; Earp 2016b; Earp and Darby 2015). They
are learning that the foreskin may be the most touch-sensitive part of the
penis (Bossio, Pukall, and Steele 2016; Earp 2016a; Sorrells et al. 2007),
and that only 1/2 of 1 percent of boys will ever need a circumcision for
therapeutic reasons prior to the age of 18 (Sneppen and Thorup 2016;
Frisch and Earp 2016).
Many of them feel very angry (see Boyle et al. 2002; Hammond
1999; Silverman 2004); they may even use the language of “mutilation”
to describe their circumcised state (see, e.g., Watson 2014). It is not
uncommon for such men to feel as though something was “taken from
them” that they ought to have had the chance to experience for themselves,
and make a decision about in their own good time (Hammond 1999;
Watson 2014). Part of the reason for this feeling, as I have noted elsewhere,
is that “the genitals (in particular) might plausibly be seen as having a
special, even unique psychosexual significance compared to other parts
of the body, which could make their un-consented alteration more likely
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to be experienced (later on) as a harm” (Earp 2015c, 45). Another reason
might be the widespread cultural and legal norms that emphasize autonomy
and a right to (bodily) self-determination in Western societies (Ludbrook
1995; Southan 2014), as well as norms about nondiscrimination on the
basis of sex or gender. These men ask—if my sister’s genitals are protected
by law in this country, why were not mine (Maloney 2016); Indeed, there
is evidence that, conservatively, tens of thousands of English-speaking
circumcised males are currently practicing something called “foreskin
restoration” (Bigelow 1995; Carlisle 2016; Hammond 1997; Novak
2011; Schultheiss et al. 1998; Warren 1999).25 This is an arduous process
of stretching the remaining tissue from the shaft of the penis up over
the glans using weights, tapes, and other instruments, over a period of
several years. Such a sustained effort to “restore” some semblance of a
pre-circumcised state suggests that circumcision is a serious issue for a
substantial number of men.
The same is true for female circumcision. While many African women feel
enhanced by having modified genitals—feeling more beautiful, “cleaner,”
more “smooth” and “neat” (Abdulcadir et al. 2012; Manderson 2004)—
increasing numbers of them are aware of just how controversial their local
customs have become on the world stage (Hernlund and Shell-Duncan
2007). Many of them are learning about how other cultures and societies
regard the innervation and functions of the clitoris and/or labia. Some of
them are dating outside of their cultural groups—perhaps especially if they
live in an immigrant community in a Western country. They are finding out
that “cut” genitals are not considered beautiful by the prevailing groups in
such contexts, and so on (Johnsdotter and Essén 2016). Accordingly, they
may feel humiliated, deprived, diminished—and yes, “mutilated” (see, e.g.,
Abdulcadir et al. 2010; see also http://www.clitoraid.org/stories). There
is even some evidence of women seeking reconstructive surgery of their
genitals to try to reclaim what was “taken from them” when they were
too young to fully understand what was happening (e.g., Foldès, Cuzin,
and Andro 2012; Foldés and Louis-Sylvestre 2006; Paterson, Davis, and
Binik 2012; Sambira 2013).
In light of these considerations, I would like to return to my argument
about enhancement. In doing so, I wish to suggest that if a proposed
enhancement intervention has the following features, it would be morally
preferable26 for the intervention to be delayed until the individual who
will actually be affected by it can make an informed decision about the
state of his/her/their own body:
?
?
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(i) The intervention is (for all intents and purposes) irreversible (for
example, because it physically removes a part of the body—especially
a part of the body that is seen as having value by a significant
proportion of those who retain it).
(ii) The intervention can be delayed without losing the very properties
(or too many of them) that are presumed to make it an enhancement
in the first place.
(iii) The very status of the intervention as being an enhancement—as
opposed to a diminishment or even a mutilation—is contentious,
assuming a free flow of information, and that the relevant parties are
reasonably well-informed about the intervention, its likely effects,
the relevant anatomy, differing cultural perspectives regarding it,
and so on.27
How contentious? I suggest that the status of an intervention as being
an enhancement—when such an intervention irreversibly changes the body
in a nontrivial fashion (such as by removing healthy, functional tissue),
and yet can be delayed—should be very well settled in a society before
anyone takes out a knife. Perhaps the bar should be set rather high. For
example, we might say that the status of the intervention as being an
enhancement should be comparable to the status of so-called medically
necessary surgeries in Western societies. For in that case, the violation of
the child’s physical integrity might even be quite radical—and yet no one
would say that it shouldn’t be done.
CONCLUSION
My proposed framework will not be pleasing to everyone. It seems that
it might allow for at least some forms of female genital cutting/alteration
in some contexts around the world to be done for some reasons other
than purely “medical” ones. But since the local norms that might inform
such a decision cannot be simply assumed to be morally reprehensible (as
the WHO/UN seem to do for any norm that could inspire nontherapeutic
alteration of female genitals in non-Western settings), and since some
forms of female genital alteration are comparatively minor, and can
be done under sterile conditions, then it seems to me that I cannot rule
out such a possibility (no matter how unpalatable I find this conclusion
personally). At the same time, it seems that some genital-altering customs
that are popular in Western countries, such as infant male circumcision or
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[ 144 ]
female genital “cosmetic” surgeries (especially as performed on teenagers
or younger girls), might need to be considered to be much more morally
problematic than they currently are considered to be. However, I believe
that the “enhancement” principle I have proposed, along with the specific
qualifications I have offered, avoids the extremes of moral relativism (that
is, I think it would be endorsed, at least in broad terms, in most cultures
around the world) as well as cultural imperialism and moral hypocrisy
(since I suggest that it should be applied to Western practices on the very
same basis as non-Western ones). I hope this moves the debate forward
in a productive way.
EDITOR’S NOTE
Due to space limitations in the printed journal, the Acknowledgments,
Notes, and References sections of this paper are available in the online
PDF version only. See muse.jhu.edu/article/622485/file/supp01.pdf.
NOTE: In the present document, these sections have been
appended directly below.
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Kennedy Institute of Ethics Journal Vol. 26, No. 2, E-1–E-28 © 2016 by The Johns Hopkins University Press
ACKNOWLEDGEMENTS
I sincerely thank Joseph Mazor, Daniel Goldberg, Kirsten Bell, Michael
Hauskeller, Robert Darby, John Danaher, Martin O’Reilly, Francelle Wax,
Ashley Trueman, Andy Vonasch, Andrew Buskell, two anonymous review-
ers, and various members of the Department of History and Philosophy
of Science at the University of Cambridge for providing feedback on
earlier versions of this manuscript. Thank you also to Richard Shweder,
Rebecca Steinfeld, Erik Parens, Nancy Berlinger, and Fuambai Ahmadu
for in-depth discussion of some of these ideas. This work was carried out
initially at the University of Cambridge and then finished during my time
as a Resident Visiting Scholar at The Hastings Center bioethics research
institute in Garrison, New York; I am extremely grateful to Millie Solomon
of The Hastings Center for inviting me to stay on as a Visiting Scholar,
and to the entire Hastings Center staff for providing such a welcoming
environment in which to read, write, and debate. The arguments presented
in this paper are solely my own, and do not necessarily reflect the views
of any of the people just mentioned.
NOTES
1. The debate over what to call the set of practices involving nontherapeutic
modification of (female) genitalia is a minefield (see, e.g., Ahmadu 2016;
Davis 2001; Shell-Duncan and Hernlund 2000). I will mostly use “FGM,”
not because I endorse this term myself (see Earp 2014c), but because this is
the term employed by those whose position I spend the most time critiquing.
I will also use such terms as “female genital cutting,” “female circumcision,”
“female genital alteration,” and so on, as needed throughout the paper.
2. Other popular counterexamples include the Holocaust, slavery, child sacrifice,
etc. Of course, which version or versions of moral relativism these examples
are supposed to refute, and on what basis, would be a very long discussion
in its own right; for an engaging overview of the issues, see Gowans (2015).
3. In Sex and Social Justice, Nussbaum (1999) ostensibly limits herself to “cases
that involve substantial removal of tissue and/or functional impairment; I
make no comment on purely symbolic procedures that involve no removal
of tissue” (119). This hedge is a little bit misleading, however, for at least
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two reasons: (i) there are a number of FGM practices that fall between “sub-
stantial removal of tissue” and “no removal of tissue,” and (ii) the actual
cases she uses for illustration throughout her discussion, as well as the stud-
ies she appeals to, often conflate the more invasive and unhygienic forms of
nontherapeutic female genital cutting (along with their probabilistic effects)
with more minor forms or forms carried out under hygienic conditions.
4. Note that human rights can be understood in many different ways. Sometimes
they are taken to be self-evident; sometimes as being grounded in a “minimal”
human nature; sometimes they are seen as merely legal conventions, etc. See
Dembour (2006) for a nice discussion.
5. As Winter, Thompson, and Jeffreys (2002) note, the terms “Western” and
“non-Western” are not unproblematic. Nevertheless, in this paper, “the West”
shall be used to refer to “the industrialized, urbanized, wealthy nations with
high GDPs and per capita incomes, which have been shaped, culturally, eco-
nomically and politically, by Western European liberal capitalist philosophy:
namely the USA, Canada, Western Europe, Australia and New Zealand”
(Winter et al. 2002, 73); “non-Western” refers to all other nations.
6. More formally, a group (or person) is guilty of—presumably culturally bi-
ased—moral hypocrisy if:
(i) The group, call it Group A, with cultural practice A* (that Group A
believes to be permissible), draws a conclusion concerning Group B,
with cultural practice B* (that Group B believes to be permissible),
according to which B* is “objectively morally wrong,” on the basis
of perceived-to be-sufficient reasons R; AND
(ii) It is the case that if one were to apply R to A* from Group A, it would
entail that A* is “objectively morally wrong” in just the same way that
B* is, according to the original analysis used by Group A to condemn
the practice endorsed by Group B; AND
(iii) Group A has not in fact applied R to A* (for whatever reason; perhaps
A* is familiar to Group A and is therefore simply taken for granted),
OR Group A has in fact applied R to A* but only in a superficial
or self-serving manner, thus failing to reach the (otherwise justified)
conclusion that A* is “objectively morally wrong” (if B* is).
7. For one example, consider Mary Daly’s (1978) well-known statement that
“African genital mutilations” are “unspeakable atrocities . . . incapable of
being expressed in words because inexpressibly horrible” (462). Another
oft-cited example is A. M. Rosenthal’s (1995) op-ed in the New York Times:
“Here is a dream for Americans . . . . The dream is that the U.S. could bring
about the end of a system of torture that has crippled 100 million people
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now living upon this earth and every year takes at least two million more
into an existence of suffering, deprivation and disease . . . . The torture is
female genital mutilation . . . . The purpose is to insure virginity and destroy
sexual pleasure. It is a form of male control, perhaps the ultimate except
for murder.” As the rest of this essay will demonstrate, many of the most
jarring assertions from this quotation by Rosenthal are simply false, having
been (apparently) uncritically recycled from the anti-FGM activist literature
available at the time. For more on the problem of uncritical reporting on
nontherapeutic genital altering procedures in the New York Times, see Earp
(2016a).
8. It is important to acknowledge that there is a minority of “insiders” who
oppose FGM in their communities, many of whom have been effective in
combatting the practice(s) within their respective spheres of influence (see, e.g.,
Shweder 2013, 254; see also Wade 2012a). Similarly, there is a minority of
circumcised men who strongly oppose nontherapeutic childhood circumcision
(see Silverman 2004); however, they have been much less effective in gaining
recognition from the global human rights community, health agencies, and
so on (for an excellent discussion of why that may be the case, see Carpenter
2014; see also van den Brink and Tigchelaar 2012, and Kennedy and Sardi
2016).
9. By contrast, as Shweder (2013) notes: “When challenges have arisen to male
circumcision Jewish men have been willing and able to exercise their critical
reason and their considerable political and moral influence in defense of their
ethnic tradition.” He goes on: “This has not been true of the policy shaping
abilities of educated circumcised African women. On the global scene and
in legislative bodies in North America and Europe they lack visibility and
political clout. Yet, they too are attached to (and find meaning and value in)
their ethnic traditions” (354).
10. As Martha Minow (2000) notes: “Dueling accusations of false consciousness
can escalate with no end. Indeed, there is a risk of infinite regression here.
You say that women in my culture have false consciousness, but you say this
because of your own false consciousness—or I think this because of my own
false consciousness, and so forth. These kinds of exchanges are essentially
incorrigible. No facts of the matter can prove or disprove false consciousness
without a prior agreement about what one ought to want” (131). See also
the discussions by Erik Parens (2014, 145) and Daniel Weinstock (2014).
11. Note that in some parts of Northeast Africa and the Middle East, where female
genital cutting has become associated with some versions of Islam in particular,
it is sometimes regarded as being necessary for preserving a girl’s “virginity”
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and “chastity,” which I see as morally objectionable (Earp, 2014b). However,
whether the cutting is or isn’t regarded this way depends on the particular
family or community; and the extent to which it is associated with, much less
a consequence of, such sexist norms, is murky. Many scholars believe that
both male and female genital cutting rituals have pre-historical origins, and
only later came into contact with Arab–Islamic culture at which point they
may have been absorbed into, or layered on top of, pre-existing gender asym-
metries that focus on female, rather than male, sexual purity (Shell-Duncan
and Hernlund, 2000; Caldwell, Orubuloye, and Caldwell 1997). The point
is that the norms that single out women and girls as needing to be chaste
are associated with some cultures and ideologies but not others; and there is
no clear or consistent relationship between such norms and the presence or
absence of female genital cutting rites (Ahmadu 2000, 285; Abdulcadir et
al., 2012).
12. When the “moment” finally did arrive, Mandela saw “a thin, elderly man
emerge from a tent and kneel” in front of him. “Without a word, he took my
foreskin, pulled it forward, and then . . . brought down his [knife]. I felt as if
fire was shooting through my veins; the pain was so intense that I buried my
chin in my chest. Many seconds seemed to pass before I remembered the cry,
and then I recovered and called out, ‘Ndiyindoda!’ [‘I am a man!’]” (ibid.)
13. As I wrote in Earp (2016b), what the available research does suggest is that
“it is possible to remove even a great deal of tissue from the external female
genitalia and yet ‘leave enough behind’ that there is nevertheless a decent
chance that the person will be able to ‘enjoy sex’ (as measured broadly by
these kinds of studies), ‘experience pleasure during sexual intercourse,’ and
even orgasm. However, that those should be the benchmarks for acceptability
is doubtful: even if it is physiologically possible to have an orgasm after one’s
external clitoral glans has been excised (or to experience at least some degree
of pleasure during sex due to the stimulation of other parts of the vulva/
vagina that have not been removed), this does not mean that sex would be
no different if one still had one’s glans. Some women who have had parts of
their genitals removed in childhood—even if they can still ‘enjoy sex’—feel
upset, angry, violated, and mutilated, simply because of the fact that part of
their genitals [was] removed without their permission. Other women who
have undergone such procedures do not feel this way. However, there is a
crucial difference between these two cases. Anyone who would like to have
her clitoral glans, clitoral hood, or labia removed or altered (but hasn’t yet
had this done) can always undertake the surgery later; whereas, someone who
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did have those things done to her—but wishes they hadn’t been—has [little]
recourse” (from the Appendix, 30, available at: https://www.researchgate.
net/publication/285578712_In_defence_of_genital_autonomy_for_children).
14. As Dustin (2010) states, “Whether the medical lobby really believed that
there is a clear distinction between an unacceptable cultural practice and a
legitimate cosmetic operation, or whether there was pressure from private
clinics and surgeons for financial reasons is difficult to judge. But the lengthy
passage of the Act was indicative of the power of the organized medical lobby
in Britain” (15–16).
15. A similar situation exists in the United States. While anti-FGM legislation in
some jurisdictions technically includes procedures that might be “favoured
by Western women” (McColgan 2011, 17), they “use only language that
addresses the ‘ritual’ or . . . belief-based cutting of African immigrant bod-
ies,” thus “mark[ing] out relations between the state and its [citizen’s] bodies
that differ depending on birthplace, cultural context, and skin color” (Davis
(2002, 21, quoted in McColgan 2011, 17).
16. In these countries, even adult women cannot consent to “medically unneces-
sary” procedures affecting their own genitals due to very strict anti-FGM laws
(Berer 2010; Matthews 2011; Sheldon and Wilkinson, 1998). In practice,
however, women of European descent seem to have free reign to modify
their genitals for “cosmetic” reasons, whereas women of African descent
are prohibited from undertaking any such modifications. For a particularly
striking illustration of this double standard, see: https://www.youtube.com/
watch?v=Cu1gmUuDniU.
17. As noted, the “more invasive procedure” being referred to is infant male cir-
cumcision, as it is customarily practiced in the United States (and to a lesser
degree in Canada). This practice was adopted in the late 1800s from England,
where it was thought to provide, inter alia, a “cure” for masturbation and
masturbation-related ailments, both physical and spiritual (Darby 2005,
2015), and it was vigorously promoted on those grounds by John Kellogg,
the inventor of cornflakes, among other influential religious men of New
England. As Kellogg (1889) wrote: “A remedy [for masturbation] which is
almost always successful in small boys is circumcision. The operation should
be performed . . . without administering an anesthetic, as the brief pain at-
tending the operation will have a salutary effect upon the mind, especially
if it be connected with the idea of punishment” (295). Circumcision was
also heavily promoted by Lewis Sayre, an ambitious orthopedic surgeon of
the era, who “claimed he was successful in using male circumcision to cure
paralysis and hip-joint disease, and to ‘quiet nervous irritability.’ He later
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extended his treatment to hernia and stricture of the bladder” (Aggleton
2007, 18). By 1894, American physicians had identified “an astounding array
of maladies that could be cured through male circumcision. These included
eczema, oedema, elephantiasis, gangrene, tuberculosis, hip-joint disease,
enuresis, general nervousness, impotence, convulsions and hystero-epilepsy”
(Aggleton 2007, 19). Today, some American physicians continue to promote
circumcision (Carpenter 2010), primarily as a form of partial prophylaxis
against sexually transmitted infections—that is, infections to which the child
may one day be exposed, depending upon his future behavior, and for which
there are alternative modes of prevention (see Frisch and Earp 2016). For
example, the American Academy of Pediatrics (AAP) has recently suggested
that the potential health benefits of neonatal circumcision “outweigh” the
associated risks of the surgery in developed countries (Blank et al. 2012;
but see Darby 2015), a view that was later echoed by the U.S. Centers for
Disease Control and Prevention (CDC 2014a, 2014b). However, this conclu-
sion is inconsistent with that reached by medical bodies outside of the United
States (see Frisch and Earp 2016 for a discussion), and both the AAP and
CDC have been criticized on scientific grounds by representatives from peer
organizations in England, Canada, and mainland Europe (Frisch et al. 2013,
Kupferschmid et al. 2015; see also van Howe 2015). Acknowledging these
criticisms, a key AAP task force member later retreated from the “benefits
outweigh the risks” claim in a published editorial, citing a “lack of a univer-
sally accepted metric to accurately measure or balance the risks and benefits”
as well as “insufficient information about the actual incidence and burden
of nonacute complications” (Freedman 2016, 1). Nevertheless, a majority
of American males continue to be circumcised, and the ones who are, tend
to elect circumcision for their sons. The most commonly stated reasons are
“so that he will look like his father,” and “so that the penis will be easier to
clean” (Brown and Brown 1987; Rediger and Muller 2013). A circumcised
penis is considered “normal” in the United States, and an “uncircumcised”
(intact) penis “abnormal.” The surgery is performed on healthy infants, and
it involves the removal of approximately 50% of the motile skin system of
the penis (Taylor, Lockwood, and Taylor 1996). Despite updated AAP guide-
lines (Blank et al. 2012), it is still done in many cases without an anesthetic
(Yawman et al. 2006).
18. This “wedge” strategy is apparent in the WHO/UN’s very choice of termi-
nology. As they discuss in an Appendix, “During the first years in which the
practice was discussed outside of practicing groups, it was generally referred
to as ‘female circumcision.’ This term, however, draws a parallel with male
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circumcision and, as a result, creates confusion between these two distinct
practices” (WHO/UN 2008, 22). Therefore, the female forms of genital cut-
ting were re-labeled “Female Genital Mutilation.”
19. With respect to the issue of health benefits as a presumed point of contrast
between male vs. female circumcision, there is the potential for a self-fulfilling
prophesy here. The claim is that, in contrast to male circumcision, female
genital cutting has “no known health benefits.” However, the WHO and
other Western agencies fund research only into the question of potential
health benefits of male circumcision (for a recent discussion see Bell 2015).
They do not fund research into the question of the potential health benefits
of female circumcision (presumably because such circumcision is regarded by
these organizations as being obviously impermissible, no matter how minor
or sterilized), and instead fund research looking exclusively for harms (see
Hodžic´ 2013). As I have noted elsewhere (internal references omitted): “On
the question of health benefits, suppose it could be shown that removing the
labia majora of infant girls reduced their risk of acquiring a urinary tract
infection (since there would be fewer folds of moist genital tissue in which
bacteria could find a home), as well as, say, cancers of the vulva—or even
HIV. It is not biologically implausible. In fact, in countries in which female
‘circumcision’ is culturally normative, it is often said to confer a range of such
benefits, including ‘a lower risk of vaginal cancer . . . less nervous anxiety,
fewer infections from microbes gathering under the hood of the clitoris, and
protection against herpes and genital ulcers.’ In addition, female ‘circumcision’
in such countries is often described as ‘more hygienic.’ . . . Nevertheless, it is
actually illegal in Western countries to conduct the very research by which
such ‘health benefits’ could be ‘discovered’ in the first place. This is because
nontherapeutic surgeries performed on the genitals of healthy girls—no matter
how slight, nor under what material conditions—are deemed to be impermis-
sible mutilations in Western law” (Earp 2015b, 3; see also Earp 2015a). Tying
these strands together, Kirsten Bell (2005) has highlighted the contradictory
nature of the WHO/UN policies on the question of health benefits: “[They]
seek to medicalize male circumcision on the one hand, oppose the medicaliza-
tion of female circumcision on the other, while simultaneously basing their
opposition to female operations on grounds that could legitimately be used
to condemn the male operations” (131).
20. I would like to say one more word, while we are on the topic of sex-based
discrimination. There are some countries and cultures that do in fact dis-
criminate on the basis of sex in their evaluations of the permissibility of
nontherapeutic alterations to healthy genitals. However, most of them are
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not in Africa or the Middle East. Instead, they include such countries as the
United States, England, Australia, New Zealand, Canada, and most of the
countries of Europe. In these societies, it is considered permissible for adults
to operate only on the healthy genitals of male children and intersex children.
By contrast, any adult who operated on the healthy genitals of a female child,
no matter to what extent, and regardless of the context or parental motiva-
tion, would be subject to criminal prosecution.
21. I am grateful to Joseph Mazor for helping me think through these issues. As
Mazor argues in a yet-to-be-submitted paper (a draft of which I have read),
it is reasonable to think that a child’s right to bodily integrity should be ana-
lyzed in terms of the child’s interests: if a breach of the child’s body envelope
counts in favor of the child’s best interests overall, then (generally speaking)
this breach will not be a violation of the child’s right to bodily integrity. That
said, the question remains: how do we know what is, in fact, in the child’s
best interests when it comes to contested body-envelope breaches, and who
should get to decide (Earp 2016d)? As McMath (2015) notes, when it comes
to genital-altering procedures in particular, people strongly disagree over
what constitutes a benefit vs. harm in the first place, as well as with respect
to the questions of personal relevance and perceived relative magnitude of
both benefits and harms (see Frisch and Earp 2016 for further discussion).
For example, “Some people believe [that male] circumcision benefits the
child by bringing him closer to God, while others disagree. In light of such
disagreement, some commentators conclude that the parents should decide”
(McMath 2015, 689). But this does not necessarily follow. After all, “the
child will have an interest in living according to his own values, which may
not reflect those of his parents . . . . Only the child himself, when he is older,
can be certain of his values.” Thus, “if disagreement over values constitutes
a reason to let the parents decide, it constitutes an even stronger reason to
postpone the decision until the child himself can decide” (ibid.). This is similar
to the view I defend in the concluding sections of this paper.
22. Please note that a proposed intervention might only turn out to be an enhance-
ment (i.e., in the child’s best interests, overall) due to manifestly unjust social
pressures or other problematic externalities; in such a case, the intervention
would be morally objectionable for other reasons than its role in affecting
the child’s welfare—i.e., insofar as it would serve to perpetuate those unjust
pressures (etc.) which individuals and society should try to mitigate rather
than reinforce. But (a) the intervention itself would not cease to be an enhance-
ment, as I have defined it, and (b) it still might be permissible for parents to
authorize it for the sake of their child’s overall well-being, depending on a
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range of factors (a classic argument here is that parents should not sacrifice
the welfare of their children on the altar of attempting to change problem-
atic social norms; see, e.g., Parens 2006). Spelling out the conditions under
which a putative enhancement would become strictly impermissible due to
negative externalities is unfortunately beyond the scope of this essay; but see
Carmack, Notini, and Earp (2015) for a hint of my views.
23. I do not suggest that the age of legal majority is the same thing as, nor even
a good approximation of, “having the capacity to provide meaningfully in-
formed consent” to some intervention. That capacity develops gradually and
in different ways between individuals (and across cultures); it also depends
on the intervention in question. Typically, the riskier or more controversial
the intervention, the higher the threshold for meaningful consent. Thus, an
appropriate age for providing meaningful consent to, say, getting braces,
could very well be lower than the age for providing meaningful consent
to an irreversible genital surgery that removes sensitive tissue. But I expect
that the precise age would depend in large part upon local/contextual fac-
tors—and would therefore not be the sort of thing that one could determine
“universally” for all cultures.
24. There are of course well-documented cases of men feeling harmed by their
circumcisions prior to the age of the Internet (see, e.g., Darby and Cox, 2008);
it is just that it has become much easier for such men to find each other and
share their stories, etc.
25. Ron Low is the owner of a foreskin restoration device company called TLC
Tugger (http://tlctugger.com). In response to my request for an estimate of
how many men are engaged in foreskin restoration using just his devices
(email dated March 25, 2015), Low writes: “For the 62-day period starting
January 1st, 2015 I helped 892 nonrepeat customers start restoring. In the
62-day period that’s 14.4 per day. In a comparable 365-day year that would
be 5,251 men I’d expect to start with TLC gear. This is conservative since
the demand continues to grow, and each quarter shows more customers than
the prior one. In 2010 we surveyed online English speaking restorers and
saw that only 77 out of 995 respondents has one of my devices. So assuming
that market share I am willing to speculate that the total number of online
English-speaking men who will start restoring this year is at least (5,251 X
995)/77, or 67,854. So 67,854 English-speaking actively-online men start
restoring per year . . . My nonrepeat customer base has been growing 4%
per year for the last 10 years, which gives rise to a total active restoring-for-
10-years-or-less population of about 572,370. This doesn’t include guys with
no online presence, and guys with not enough English language skill to find
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me, so I call it a very conservative estimate. Of course since there are some
gross assumptions, it should be reported rounded off, say 570,000. While
this is an unpublished number, I do have 10 years of tax returns attesting to
the fact that I make my living selling these devices.” Low then provided sales
records for the 62-day period mentioned above in response to my request
for additional information that would allow me to substantiate these figures.
26. The list that follows is not meant to be a set of necessary and sufficient con-
ditions for “absolute” moral permissibility or impermissibility; instead, it
is a suggestion, an offering—a decision-making heuristic that I think most
parents from a range of cultural backgrounds would find reasonable and
would therefore be inclined to accept upon careful reflection.
27. A skeptic of my argument might ask: what is the moral significance of
whether some procedure/intervention is “contentious”? After all, might not
someone live in a totalitarian regime that “brainwashed” all of its citizens
into complacency about a morally problematic practice that otherwise
would be considered controversial? In such a case, would I really want to
argue that the practice was permissible (because not contentious)? Or, what
if some morally benign practice were in fact contentious in some context,
but only because those debating the practice were seriously misinformed, or
perhaps just wanted to create a fuss? These are not unreasonable objections.
Accordingly, I have added the qualifications above concerning a free-flow
of information, a basic level of being informed, and so on. Nevertheless, as
concerns the present topic, such hypothetical qualifications are not actually
needed. This is because, when it comes to the actual types of interventions I
am considering—namely nontherapeutic alterations to children’s genitals—
they are contested, and are so in societies that do have access to information,
exposure to different norms, etc. Of course, if they were not contested in
some context, this would not entail that they were morally unproblematic; it
might just mean that people’s awareness of the morally problematic features
of the practices was too low to have an impact on the public debate. Given
the increasing interconnectedness of the globe through information technol-
ogy, however, it seems to me that fewer and fewer people, regardless of their
cultural setting, will be in a position not to know that many women, men,
and intersex people feel seriously mutilated by their childhood genital altera-
tions; and I argue that parents’ assessments of the child’s best interests should
be strongly influenced by this information, weighing in favor of delaying the
intervention until an age of consent.
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